1. Emergency Medicine Junior Teaching Programme Aberdeen Royal Infirmary Adult Syncope Evaluation in the Emergency Department Jamie Cooper Teaching 4 th March 2009

2. Emergency Medicine Junior Teaching Programme Aberdeen Royal Infirmary Syncope Transient LoC with an inability to maintain postural tone followed by a spontaneous recovery. ~3% all ED attendances 1-6% medical admissions Wide differential diagnosis Assessment can be difficult

3. Emergency Medicine Junior Teaching Programme Aberdeen Royal Infirmary Causes Faint (vaso-vagal) Seizure (cerebral anoxia) Cardiac Orthostatic Hysterical Myotonica Congenita

4. Emergency Medicine Junior Teaching Programme Aberdeen Royal Infirmary ED Management in the UK Thakore et al. 1999 –Poor documentation of relevant syncopal symptoms. –ECG not recorded in 25% cases –28% of patients with an abnormal ECG and 40% patients with known heart disease were discharged from the ED

5. Emergency Medicine Junior Teaching Programme Aberdeen Royal Infirmary Differentiation Hx and examination reveals cause in ~40% –Stigmata of seizure –Pre-syncopal symptoms –Situation –Preceding chest pain, headache or SoB –Recurrent episodes –Recovery period/post-ictal phase –Witness account –Drug history –Family history

6. Emergency Medicine Junior Teaching Programme Aberdeen Royal Infirmary Examination & Investigations Careful cardiovascular examination –Lying and standing BP (postural drop) –Carotid Sinus Massage ECG BM If young female  hCG Rectal examination +/- FBC/HCT Other blood tests rarely discriminate

7. Emergency Medicine Junior Teaching Programme Aberdeen Royal Infirmary ECG ECG is usually normal –Dx in 2%-6% Martin et al. Ann Emerg Med 1984;13:499-504 Kapoor W. Medicine 1990; 69:160-75 Virtually any abnormality (save non specific ST changes) is a multivariate predictor for dysrhythmic cause and increased mortality. Martin et al. Ann Emerg Med 1997;29:459-66 Oh et al. Arch Intern Med 1999;159:375-80

8. Emergency Medicine Junior Teaching Programme Aberdeen Royal Infirmary Cardiovascular Investigations Routine use of cardiac markers in syncope has a low (<1% diagnostic yield) No evidence for Echo in ED risk stratification. 24 hour tape monitoring and loop recording Tilt table

9. Emergency Medicine Junior Teaching Programme Aberdeen Royal Infirmary Who then do we admit and why? In general presence of underlying cardiac disease is main risk factor in syncope Kapoor in 1983 (N Engl J Med 1983;309:197-204) –Sudden death (<24 hrs) cardiac 24% cf. non cardiac 4% Other short term outcomes not available to inform decision. Most evidence is for 6/12 to 1yr follow up –(1yr mortality 18-33% for cardiac syncope cf. 3-4% for non-cardiac causes)

10. Emergency Medicine Junior Teaching Programme Aberdeen Royal Infirmary ACP Recommendations Ann Intern Med 1997;126:989-96 Ann Intern Med 1997;127:76-86 1) Admission indicated –Hx of CAD, CCF or VT –Chest pain –Signs of CCF, valve disease –ECG findings of ischaemia, arrhythmia, long QT or BBB 2) Admission often indicated –Sudden LoC with injury, palpitation or exertion –Frequent episodes –Suspicion of CAD or arrhythmia –Significant postural hypotension –Age > 70 years Studied in the UK by Crane et al. Emerg Med J 2002;19:23-27 1 year mortality of 36% (1), 14% (2), 0% (3)

11. Emergency Medicine Junior Teaching Programme Aberdeen Royal Infirmary ACEP Recommendations Ann Emerg Med 2001;37:771-6  Level A (No recommendations)  Level B (Consider Admit)  Hx of CHF or ventricular arrhythmias.  Chest pain or suspicion of ACS  Clinical evidence of CHF or valve disease  ECG evidence of ischaemia, arrhythmia, prolonged QT or BBB  Level C (Admit)  Age > 60 yrs  Hx of CAD or congenital heart disease  Family Hx of unexpected sudden death  Exertional syncope in younger patients without obvious benign aetiology for syncope

12. Emergency Medicine Junior Teaching Programme Aberdeen Royal Infirmary OESIL Risk Score 4 characteristics –Age > 65yrs –Hx of cardiovascular disease –Syncope without prodrome –Abnormal ECG 12-month mortality –Score 00% –Score 10.8% –Score 219.6% –Score 334.7% –Score 457.1% European Heart Journal 2003;24:811-819

13. Emergency Medicine Junior Teaching Programme Aberdeen Royal Infirmary San Francisco Syncope Rule Prospective study patients presenting to a US ED Derived clinical decision rule with five risk factors 1.Abnormal ECG 2.Anaemia (HCT<30%) 3.Shortness of breath 4.Systolic BP< 90mmHg 5.Hx of CCF

14. Emergency Medicine Junior Teaching Programme Aberdeen Royal Infirmary San Francisco Syncope Rule  Sensitivity 98% (95%CI 89%-100%)  Specificity 56% (95%CI 52%-60%)  LR-ve 0.03 (95%CI 0.01-0.24)  LR+ve 2.23 (95%CI 2.03-2.45) Ann Emerg Med 2004;43:224-232 & Ann Emerg Med 2006;47:448-454 Serious Outcome Decision RuleYesNo Positive52290 Negative1370

15. Emergency Medicine Junior Teaching Programme Aberdeen Royal Infirmary Any Questions?

16. Emergency Medicine Junior Teaching Programme Aberdeen Royal Infirmary Don’t forget those goats!