1. COLLAPSE ? CAUSE

2. WHY IS THIS AN IMPORTANT TOPIC TO MASTER? One of the great skills in EM is the ability to risk stratify patients accurately and to formulate an informed management plans. It is also important to enable the patient to make an informed decision in understanding proposed investigations, their risks and benefits and consenting to further investigation.

3. A CASE So lets think of a case to start with 60 years man Comes in following a collapse at the shops, an ambulance is called and the paramedics bring him to your ED. On arrival he’s alert and orientated GCS 15 Pulse 80 bpm BP 120/80 RR 16 SpO2 on air 99% Temp 36.2 BM 5.7 He’s been well for the past few days, no history pointing you towards a diagnosis, no significant PMH. No meds and his examination is completely unremarkable,

4. WHAT WOULD YOU DO WITH THIS PATIENT?

5. THE PAPER By Quinn J et al. Annals of Emergency Medicine 2006 ‘Prospective validation of the San Francisco Syncope Rule to predict patients with serious outcomes’

6. ABOUT THE SANFRANCISCO SUNCOPE RULE The rule that they’re attempting to validate is the ruel they produced to risk stratify patients into low and high risk of morbidity and mortality. It is also referred to as the CHESS score, which stands for….. C – ongetsive cardiac failure H – ct < 30% E – CG abnormality – any S – ystolic BP < 90 mmHg S – hortness of breath in the history

7. INCLUSION CRITERIA Patients with a symptom of syncope Syncope was defined as a ‘transient loss of consciousness with return to baseline neurological function Prospective study between 2002-2004

8. EXCLUSION CRITERIA Trauma-associated LOC Alcohol/drug involvement Definite seizure

9. OUTCOME MEASURES 30 follow up after the index visit to the ED and determined short term outcomes that would mandate emergency admission Short term serious outcomes Death MI Arrhythmia PE Stroke SAH Significant haemorrhage/anaemia requiring transfusion Any condition causing/likley to cause a return visit Procedural intervention to treat a related cause of syncope

10. ACUTE INTERVENTIONS DEFINED AS….. A procedure required to treat a condition related to the patient’s syncope Dialysis Pacemaker insertion Surgery for valvular heart disease Baloon pump insertion Vasopressor use Surgery for an AAA/ruptured spleen/ectopic pregnancy Endoscopy for varices

11. RESULTS Information gathered for 767 visits Average age of 61 years, 13.7 % of patients were deemed to have had a serious outcome San Francisco rule classified 52% of patients as high risk If the rule had been used to determine admission/discharge decisions it would have decreased admissions by 7% The study was powered to determine sensitivity and specificity with 95 % Cis within 10% (which it just failed to achieve with the sensitivity). The rule was 90% sensitive (95 % CI 89-100%) and 56 % specific (95% CI 52-60%) in predicting serious outcomes

12. REFERENCES Quinn J, McDermott D, Stiell I, Kohn M, Wells G. Prospective validation of the San Francisco Syncope Rule to predict patients with serious outcomes. Ann Emerg Med. 2006;47(5):448-54.