1. SYNCOPE

2. ER重點: 排除life-threatening 因素
Syncope protocol
Syncope定義：
Sudden transient loss of consciousness with loss of postural tone
spontaneous return to baseline neurologic function requiring no resuscitative efforts.
D/D:
Near-syncope
Dizziness, Vertigo
seizure
ER重點: 排除life-threatening 因素

3. Pathophysiology
A drop in cardiac output
vasospasm

4. Etiology (Tintinalli Table 52-1)
Reflex-mediated
Vasovagal
Situration: cough, micturition, defecation, swallow, neuralgia
Carotid sins syndrome
Orthostatic hypotension
Psychiatric
Neurological
TIA
Subclavian steal
Migraine
Medication
Beta-blocker, CCB…
Cardiac
Structural CV disease
VHD
Cardiomyopathy
Pul. hypertension
Myxoma
Pericardial disease
Aortic dissection
Pul. embolism
AMI
ACS
Dysrhythmias
Bradycardia
Tachycardia

5. History: 6個P
Pre-prodrome activities
Prodrome symptoms- visual symptoms, nausea
Predisposing factors- age, chronic disease, family history of sudden death
Precipitating factors- stress, postural symptoms
Passerby witness- what did they see?
Post-ictal phase, if any  suggests seizure

6. Physical Exams
Evaluate for trauma
Orthostatic vital signs
Difference in BP in both arms (aortic dissection or subclavian steel syndrome)
Careful CV examination, including murmurs, bruits, and dysrhythmia
Rectal exam (GI tract bleeding)
Careful neurologic examination

7. Abnormal ECG: syncope之相關EKG findings:
在評估病人同時應完成 NE
complete EKG
orthostatic vital signs
Abnormal ECG: syncope之相關EKG findings:
prolonged intervals(QRS, QTc)
severe bradycardia (high degree AV-block)
pre-excitation
evidence of myocardial infarction
low voltage in standard limb leads
abnormal conduction syndrome (eg, WPW and Brugada syndrome)

8. Laboratory Exam:
CBC  occult hemorrhage
Cardiac enzyme  ischemia
Pregnancy test in reproductive age female
Electrolytes  profound dehydration or diuretic use
D-Dimer  pulmonary embolism

9. Imaging:
Cardiac Echo  structural defects
ECG monitoring  dysrhythmia
CXR  CHF, dissection
Chest CT  pulmonary embolism
Head CT  abnormal NE or TIA

10. Treatment and disposition
Admission: specific cause of syncope
cardiac Syncope- Arrhythmia, Myocardial infarction, Cardiac tamponade
Pulmonary Embolism
Neurologic syncope- SAH, Subclavian steal syndrome, TIA
Significant hemorrhage- GI bleeding, Trauma, Ruptured internal organ (spleen, ectopic pregnancy, ovarian cyst)
Severe dehydration or electrolyte imbalance

11. Treatment and disposition
Admission: unspecific syncope with high risk
History of cardiac disease, especially heart failure
Persistent SBP< 90 mmHg
SOB with event or during evaluation
Hematocrit < 30
Older age and associated cormobidities
Family history of sudden cardiac death
Unexplained syncope
Discharge
Reflex mediated syncope
Orthostatic hypotension(非 hemorrhage induced)
Medication related syncope

12. Protocol

13. Reference
Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice, 6th ed., 2006 Mosby.
Tintinalli et al: Emergency Medicine: A Comprehensive Study Guide. 6th ed. 2004
Schaider et al: Rosen & Barkin's 5-Minute Emergency Medicine Consult. 3rd ed Lippincott Williams & Wilkins.
Linzer, M, Yang, EH, Estes, NA, 3rd, et al. Diagnosing syncope. Part 1: Value of history, physical examination, and electrocardiography. Clinical Efficacy Assessment Project of the American College of Physicians. Ann Intern Med 1997; 126:989.
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