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Syncope

Resources

ED assessment of syncope focuses on differentiating potentially life threatening cardiac syncope from benign causes such as neurocardiogenic (situational, vasovegal syncope) In general if there is reasonable suspicion of a cardiac cause  patients should be admitted for work up on telemetry.

DDx:

Life threatening cardiovascular causes:

Arrhythmia - Brady and tachy
Valvular Dysfunction (Eg: Severe AS)
Myocardial Dysfunction - (ischaemia, cardiomyopathy, myocarditis - poor pump and @ risk of arrhythmia)
Outflow issues - Eg: PE / Dissection
Preload issues (EG: Major haemorrhage - unlikely to present as isolated syncope in a well patient)

Less sinister Causes

Neurocardiogenic -Vasovegal / situational syncope (eg defecation)
Orthostatic -Postural hypotension - think about contributers - meds, dehydration, autonomic dysfunction)
Syncope Mimics - eg seizure, psychogenic


Assessment:

History.

Careful history is the cornerstone of assessment of syncope. Focus on the nature of the syncope, associated symptoms and the risk profile of the patient.

Nature Of Syncope

Sinister Features:
Unheralded, Seated / lying at time, Exertional

Less Sinister:
During defecation / urination,  preceeded by noxious stimuli (eg: abdominal cramping in gastroenteritis, IV insertion), Positional - orthostatic

Associated symptoms:

Sinister
Dyspnoea, Chest pain, Palpitations

Less Sinister:
Preceded by nausea / dizziness.

Risk profile of patient:

Sinister:
Family history of premature cardiac death / cardiomyopathy, Known cardiac disease (esp CCF, Valvular disease, Increasing Age.

Examination:

Rarely contributory but a focussed cardiovascular exam is important - with attention to murmurs and signs of CCF.


Investigation:
BSL
ECG: Most important investigation in syncope.

Know what you are looking for when examining a syncope ECG. The following findings can be subtle and indicate a high risk and warrant admission. Actively exclude them every time you see a syncope ECG). I use the mnemonic ' Can Quick BRAD Walk Home'

Can (Conduction blocks - 2nd degree, 3rd degree, Bifascicular Block)
Quick (QT - long (+ short -rare)
B (Brugada)
R (RV ischaemia and ischaemic changes in general, esp if associated chest pain)
A (ARVD)
D (Dilated Cardiomyopathy - non specific ECG findings but may have small voltages)
Walk (WPW)
Home (HCM)


Other investigations are rarely helpful and should be tailored to the patient, eg FBC in the clinically anaemic patient or those with a history of bleeding) Electrolytes in the dehydrated patient. CXR if associated chest pain.

Risk Stratification tools
Scoring tools exist to attempt to quantify risk in syncope  and guide decisions RE admission. (Eg: San Francisco Syncope Rule) Use them with care. (Are you really going to discharge the patient with the family history of sudden cardiac death who presents with exertional syncope just because the SFSR score is 0?)

Resources:

http://lifeinthefastlane.com/ecg-library/
A great resource for reviewing some of the ECG findings mentioned above.
Emergency Medicine - Cadogan& Brown

Rosens Emergency Medicine
Syncope    Guidelines   TPCH
San Francisco Syncope Rule Calculator
Review - Syncope Risk Stratifcation
Copyright © 2015
  • Home
  • Guidelines
    • AAA Rupture
    • Acute Coronary Syndrome
    • Anaphylaxis
    • Aortic Dissection
    • Appendicitis
    • Asthma
    • Backpain
    • Bowel Obstruction
    • Bronchiectasis
    • Burns
    • Chest Pain >
      • ADP Chest Pain Pathway
    • Cholecystitis
    • Confusion
    • COPD
    • Diverticulitis
    • DKA
    • DVT
    • Eating Disorders
    • Febrile Neutropaenia
    • Fractures >
      • Bier's block procedure form
      • Fractured neck of Femur
    • Funnel Web Spider Bite
    • Headache
    • Influenza Like illness
    • Meningitis
    • Obstetrics >
      • Hypertensive disorders in pregnancy
      • Normal Birth
      • PPH
      • Preterm labour
      • Still birth
      • Trauma in pregnancy
    • Pancreatitis
    • Paracetamol OD
    • Pathology Ordering
    • Peri-anal abscess
    • Pertussis
    • Pneumonia
    • Pneumothorax
    • Podiatry
    • Procedural Sedation >
      • Procedural Sedation
    • Pulmonary Embolus
    • PV Bleeding in Early pregnancy >
      • EPAU - Early Pregnancy Assessment Unit
    • Redback Spider Bite
    • Ring cutter use
    • Seizure
    • Septic Arthritis
    • Use of Restraints
    • Stroke / TIA
    • Sepsis
    • Smoking cessation
    • Snake Bite
    • Syncope >
      • Telemetry guideline
    • TIA
    • Tonometer use
    • Antidotes
    • Dagibatran reversal guidelines
    • Funnel Web Spider Bite
    • Redback Spider Bite
    • Paracetamol OD
    • Snake Bite
    • Warfarin Reversal Guidelines
    • Trauma >
      • C-spine injury
      • Head Injury
      • Imaging Guidelines
      • Trauma in pregnancy
      • Sutures
    • Abdominal Pain
    • Allergy / Anaphylaxis
    • Antimicrobial Guidelines
    • Asthma & Wheeze
    • Behavioural Disturbance
    • Boils - Staph decolonisation treatment
    • Bronchiolitis
    • Buckle fractures
    • Burns
    • Cervical Spine Guideline
    • Chest Pain (Paediatric)
    • Child Protection
    • Constipation
    • Croup
    • DKA
    • Drowning
    • Eating Disorders
    • Fever
    • Fluids in Kids
    • Foreign Bodies
    • Gastroenteritis
    • Headache
    • Head Injury
    • High Flow Nasal Cannula Oxygen
    • Hypoglycaemia
    • Jaundiced Neonate
    • Limping in children
    • Malaria
    • Meningitis
    • Oncology Emergencies
    • Otitis Externa
    • Otitis Media
    • Paediatric Fracture Clinic Referral
    • Paracetamol Poisoning
    • Petechial Rash
    • Pneumonia (CAP)
    • Seizures / Status Epilepticus
    • Sepsis Guideline
    • Tetanus Prophylaxis
    • Torticollis
    • UTI NICE Guideline
    • Trauma in children >
      • LCCH Paeds Trauma Guidelines
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      • LCCH Massive Transfusion
    • RCH Melbourne Guidelines
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    • Accidental Poisoning
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    • Constipation
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    • DKA
    • Epistaxis
    • Eye Foreign Body
    • Febrile Convulsion
    • Fever
    • Fracture- Buckle
    • Fracture- Clavicle
    • Fracture- Elbow
    • Fracture- Finger/Toe
    • Fracture- Foot
    • Gatroenteritis
    • Glue- Lacerations
    • Head Injury
    • Jaundice
    • Otitis Externa
    • Parechovirus
    • Periorbital and Orbital cellulitis
    • Pulled Elbow
    • Seizures
    • Tonsillitis
    • Urticaria
    • Viral Illness
    • Wound Care
  • ACE the ACEM
  • Blog