Transcript SYNCOPE - Cleveland Clinic

SYNCOPE
KELLIE ZAYLOR PGY-2
OCTOBER 5, 2006
OBJECTIVES
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Discuss Causes of Syncope
Understand those causes that are an immediate
life threat to the patient
Cover important elements of the evaluation
and workup of the syncopal patient
Discuss management options
Definition
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SYNCOPE: Transient loss of consciousness
with a loss of postural tone and absence of
prolonged confusion (post-ictal period)
Basic Pathophysiology
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Caused by CNS dysfunction
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Can be secondary to hypoperfusion of brainstem
(reticular activating system) or both cerebral
hemispheres
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Blood flow can be regional (cerebral vasoconstriction)
or systemic (hypotension)
Hypoperfusion resulting in 35% or more reduction in
cerebral blood flow usually produces unconsciousness
Other CNS dysfunction: Hypoglycemia, toxins,
metabolic abnormalities, failure of autoregulation,
and primary neurological derangements
Epidemiology
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12-48% of general population experiences a
syncopal event sometime in their lives
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Institutionalized pts >75 years old, have 6% annual
incidence
15-50% of children have at least one episode
Five percent of ED complaints
1-6% of hospitalized patients have syncope as
a reason for admission
Statistics
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Most common cause overall: vasovagal
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No identifiable cause in 30% of cases
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17-18% of cases attributable to arrhythmias
Statistics (cont’d)
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30% of athletes dying during exercise had
syncope as a sentinel event
Factors associated with 1 year mortality
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Abnormal ECG
Ventricular dysrhythmias
Presence of CHF
Age > 45 years old
Etiology: Life threatening
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Wide range of causes: Seek out the life threatening
ones!
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Cardiac
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Acute Coronary Syndrome
Dysrhythmias (WPW, Blocks, Prolong QT)
Structural Abnormalities (Aortic Stenosis, Hypertrophic
Cardiomyopathy {HCM} )
Vascular
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Aortic Dissections
Ruptured Aneurysms
Other Hemorrhage (GI bleed, Ruptured Ectopic Pregnancy)
Etiology: Life threatening
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Pulmonary
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CNS
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Pulmonary Embolism
Pneumothorax
Ischemia/Hemorrhage
Toxic/Metabolic Derangements
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Glucose, Electrolyte abnormalities, Ingestions, CO
poisoning etc.
Etiology: Other Causes
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Hyperventilation
Vasovagal (Emotion, Pain)
Carotid Sinus Sensitivity (Necktie/shaving)
Miscellaneous Reflex
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Cough, sneeze
Exercise
GI-swallowing, vomiting, defecation
Postmicturition
Increased intrathoracic pressure (weightlifting)
Hypoperfusion (Orthostasis, Anemia)
Etiology: Other Causes
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Seizures
Narcolepsy
Psychogenic
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Anxiety
Conversion disorder
Somatization disorder
Panic disorder
Breath holding spells
Etiology: Drugs
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CV
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Bblockers, vasodilators, diuretics,
antihypertensives, QT prolonging agents,
dysrhythmics
Psychoactive
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Anticonvulsants, antiparkinson, CNS depressants,
MAOI, TCA, narcotics, antihistamines,
cholinesterase inhibitors
Etiology: Drugs
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Other drugs to consider
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Drugs of abuse (THC, cocaine, etoh, heroine)
Diabetes medications
Neuropathic drugs (vincristine)
NSAIDS
Bromocriptine
Evaluation of Syncope Patient
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Rapid Assessment: If patient unstable: ABC’s
and other necessary means of stabilization
BUT…
Since syncope is a transient event, most
patients are able to give history
Also important to talk to family members or
other individuals at the scene
Evaluation
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Important information to gather…
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Abrupt or gradual onset
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If it is abrupt while sitting or supine, suspicious for
cardiac etiology
Events prior to the syncopal episode
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Associated with exertion? Possible outflow obstruction
Hot environment? Orthostasis
Associated with Chest pain/SOB? Possible MI,
Dissection, PE, Pneumothorax
Evaluation
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(cont’d) Events prior to syncopal episode
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Headache? Possible intracranial hemorrhage
Abdominal Pain? r/o Dissection, Ruptured aneurysm or
Ectopic pregnancy
Diaphoresis/lightheaded/dim vision? Vasovagal
Aura? Consider seizure
What happened during the event and how long did it
last?
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Tonic-clonic mvmts? Possible seizure
Trauma from fall/ or did they pass out before they fell?
Further information to distinguish
between Syncope vs. Seizure
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Factors favoring syncope
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Nausea or diaphoresis preceding spell
Orientation upon awakening
Age > 45 years old
Prolonged sitting or standing prior to episode
History of CHF or CAD
Factors favoring seizure
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History of seizure disorder
Tongue biting
Post-ictal period
LOC > 5 minutes
Preceding Aura
Age < 45 years old
Observed unusual posturing/jerking or head turning
History
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Pertinent Past Medical History
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History of Seizure disorder
CAD
CHF
Aneurysms
Aortic Stenosis
GI bleed
Hypertension
Diabetes
Migraines
Medications
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Remember to get a full medication list and ask
about…
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Changes in meds
Compliance with medications
Eating after medications (i.e. Insulin)
Physical Exam
System
Pivotal Finding Significance
Vital signs
Pulse rate/rhythm
RR and depth
Blood Pressure
Temperature
Skin
Color, diaphoresis
Arrhythmias
Tachypnea suggests hypoxia,
hyperventilation or PE
Underlying shock may be present and
may contribute to syncope in 15-30%
pts.
Fever from sepsis may cause orthostasis
Signs of decreased organ perfusion
Physical Exam
System Pivotal Finding Significance
HEENT
Tenderness/deform.
Papilledema
Breath
Signs of trauma
Increased ICP
Ketones for DKA
Neck
Bruits
JVD
Source of cerebral emboli
Right heart failure from ischemia,
tamponade or PE
Lungs
Breath sounds,
crackles, wheezes
Infection, left heart failure from
ischemia, PE
Physical Exam
System Pivotal Finding Significance
Heart
Systolic Murmur
Rub
Aortic stenosis, HCM
Pericarditis, tamponade
Abdomen
Pulsatile mass
AAA
Rectum
Hematest stool
Anemia, hypovolemia
Pelvis
Uterine bleeding,
adnexal tenderness
Anemia, ectopic, hypovolemia
Extremities Pulse equality in
upper extremities
Subclavian steal, aortic dissection
Neurologic Mental status, focal
deficits
Seizure, stroke, other primary neurologic
disease
Diagnostic Studies: What to look
for…
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12 lead EKG
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Orthostatics
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Orthostatic hypotension
CBC/Electrolytes, Glucose
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Dysrhythmias, ischemia
Anemia, metabolic abnormalities, hypoglycemia
B-HCG
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Pregnancy ? Normal IUP vs ectopic
Diagnostic Studies: What to look
for…
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Drug screen and therapeutic drug levels
Serum etoh
ABG
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CXR
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Hypoxemia, hyperventilation
Pneumothorax, dissection
Head CT
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Check if new-onset seizure, history of trauma
Diagnostic studies: Ultrasound
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Ultrasound can quickly help identify multiple
causes.
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Abdominal
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Pelvic
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Abdominal aortic aneurysm/dissection, intraabdominal
hemorrhage
Ectopic vs. IUP
Cardiac
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Tamponade, outflow obstruction
Aortic Dissection and syncope
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Ultrasound can be invaluable if you suspect
dissection!
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Need to rule out tamponade- the most common
mechanism of death in acute aortic dissection
American Journal of Med, 2002: International
registry of aortic dissection (IRAD) collected
data on 728 pts with acute aortic dissection.
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Syncope reported in 96 (13%) of patients
Aortic Dissection and Syncope
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The study further showed that patients with acute
aortic dissection who had a syncopal episode
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Were more likely to die in the hospital (34%) than those
without (23% P=0.01)
Were more likely to have tamponade (28%) vs (8%
P=0.001)
Stroke was a more common complication (18%) vs (4%
P=<0.001)
Experienced more neurological deficits (25%) vs (14%
P=.005)
Aortic dissection and Syncope
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Patients with proximal dissections more often
had syncope than with distal dissections
19% vs 3% P<0.001
* Keep in mind that acute paraplegia secondary
to spinal cord ischemia occurs in dissections
involving the descending aorta and may be
mistaken as syncope
Aortic dissection and Syncope
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Excluding those complications discussed prior
(tamponade, stroke etc), syncope alone does
not appear to increase the risk of death.
Forty-six percent of patients with syncope had
no explanation for their LOC and could have
been caused by…
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Vasovagal secondary to pain from the dissection
Direct stretching of the baroreceptors in the aortic
wall
Admission vs Discharge
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Treat the underlying cause, and if one is found,
admit or discharge appropriately.
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Potential guideline to help physicians with
decision making called The San Franciso
Syncope Rule
San Francisco Syncope Rule
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If the patient has any of these, they are at a high risk
for a serious outcome and require admission
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At the time of triage: systolic <90
Patient complaint of SOB
History of CHF
Hematocrit <30
EKG
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Does the patient have a rhythm that is not sinus?
Does the patient have new changes on their EKG?
San Francisco Syncope Rule
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C: CHF history
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H: Hematocrit < 30
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E: EKG changes
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S: Systolic <90
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S: Short of Breath
San Francisco Syncope Rule
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If the patient does not meet any of those
criteria – the patient is at a low risk for serious
outcome requiring admission
A study was conducted in June 00-Feb 02 (J of
EM Oct 2005) comparing the application of this
rule vs physician judgment in predicting which
patients will have a serious outcome within 7
days of the ED visit
San Francisco Syncope Rule
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Study (cont’d): Serious outcomes were defined as
MI, arrhythmia, PE, hemorrhage, stroke, death.
Both physicians and the SFSR were able to predict
those who will have a serious outcome
BUT, physicians still admitted many patients even
though they felt they were low risk
If the SFSR had been utilized, there could have been
a 10% decrease in admission of the low risk group.
Low Risk Patients & Negative ED
workup
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Journal of EM 2004. A small study of 45 patients
conducted over a 3 month period of time. Patients
presented with syncope, had a negative workup in the
ED and were followed up in one month.
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If asymptomatic patients who…
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Denied any chest pain, abdominal pain or focal neurological
symptoms
Have acceptable vital signs
Lack new cardiopulmonary or neurological findings
Have normal glucose levels
Have normal or unchanged ED tracings during their ED eval.
Low risk patients and negative ED
workup
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Those patients that meet those criteria may not
benefit from hospitalization.
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Considering hospitalization is not completely benign
and may pose unforeseen risk to otherwise healthy
patients due to…
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Medication changes and errors
Instrumentation
Risk of nosocomial infections
Forced bed rest (risk of DVT, PE)
Summary
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There are many causes of syncope
Be vigilant in ruling out the life-threatening
ones!
Use the ultrasound machine
Take into account the risks of hospitalization
Sources
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Quinn, Stiell, McDermott, Kohn, Wells: The San
Francisco Syncope Rule vs physician decision
making. Am J Med 2005; 23, 782-786.
Nallamothu, Mehta, Saint: Syncope in Acute Aortic
Dissection: Diagnostic, Prognostic and Clinical
Implications. Am J Med 2002; 113, 468-471.
Junaid, Dubinsky: Establishing an approach to
syncope in the emergency department. J EM; 15,
593-599
Rosen’s Emergency Medicine: Concepts and Clinical
Practice. Chapter 20. Syncope.