syncope kellie zaylor pgy-2 october 5, 2006. objectives discuss causes of syncope discuss causes of...

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SYNCOPE SYNCOPE KELLIE ZAYLOR PGY-2 KELLIE ZAYLOR PGY-2 OCTOBER 5, 2006 OCTOBER 5, 2006

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SYNCOPESYNCOPE

KELLIE ZAYLOR PGY-2KELLIE ZAYLOR PGY-2

OCTOBER 5, 2006OCTOBER 5, 2006

OBJECTIVESOBJECTIVES

Discuss Causes of SyncopeDiscuss Causes of Syncope Understand those causes that are an immediate Understand those causes that are an immediate

life threat to the patientlife threat to the patient Cover important elements of the evaluation Cover important elements of the evaluation

and workup of the syncopal patientand workup of the syncopal patient Discuss management optionsDiscuss management options

Definition Definition

SYNCOPE: Transient loss of consciousness SYNCOPE: Transient loss of consciousness with a loss of postural tone and absence of with a loss of postural tone and absence of prolonged confusion (post-ictal period)prolonged confusion (post-ictal period)

Basic PathophysiologyBasic Pathophysiology

Caused by CNS dysfunctionCaused by CNS dysfunction Can be secondary to hypoperfusion of brainstem Can be secondary to hypoperfusion of brainstem

(reticular activating system) or both cerebral (reticular activating system) or both cerebral hemisphereshemispheres

Blood flow can be regional (cerebral vasoconstriction) Blood flow can be regional (cerebral vasoconstriction) or systemic (hypotension)or systemic (hypotension)

Hypoperfusion resulting in 35% or more reduction in Hypoperfusion resulting in 35% or more reduction in cerebral blood flow usually produces unconsciousnesscerebral blood flow usually produces unconsciousness

Other CNS dysfunction: Hypoglycemia, toxins, Other CNS dysfunction: Hypoglycemia, toxins, metabolic abnormalities, failure of autoregulation, metabolic abnormalities, failure of autoregulation, and primary neurological derangementsand primary neurological derangements

EpidemiologyEpidemiology

12-48% of general population experiences a 12-48% of general population experiences a syncopal event sometime in their livessyncopal event sometime in their lives Institutionalized pts >75 years old, have 6% annual Institutionalized pts >75 years old, have 6% annual

incidenceincidence 15-50% of children have at least one episode15-50% of children have at least one episode

Five percent of ED complaintsFive percent of ED complaints 1-6% of hospitalized patients have syncope as 1-6% of hospitalized patients have syncope as

a reason for admissiona reason for admission

StatisticsStatistics

Most common cause overall: vasovagalMost common cause overall: vasovagal

No identifiable cause in 30% of casesNo identifiable cause in 30% of cases

17-18% of cases attributable to arrhythmias17-18% of cases attributable to arrhythmias

Statistics (cont’d)Statistics (cont’d)

30% of athletes dying during exercise had 30% of athletes dying during exercise had syncope as a sentinel eventsyncope as a sentinel event

Factors associated with 1 year mortalityFactors associated with 1 year mortality Abnormal ECGAbnormal ECG Ventricular dysrhythmiasVentricular dysrhythmias Presence of CHFPresence of CHF Age > 45 years oldAge > 45 years old

Etiology: Life threateningEtiology: Life threatening

Wide range of causes: Seek out the life threatening Wide range of causes: Seek out the life threatening ones!ones! CardiacCardiac

Acute Coronary SyndromeAcute Coronary Syndrome Dysrhythmias (WPW, Blocks, Prolong QT)Dysrhythmias (WPW, Blocks, Prolong QT) Structural Abnormalities (Aortic Stenosis, Hypertrophic Structural Abnormalities (Aortic Stenosis, Hypertrophic

Cardiomyopathy {HCM} )Cardiomyopathy {HCM} )

VascularVascular Aortic DissectionsAortic Dissections Ruptured AneurysmsRuptured Aneurysms Other Hemorrhage (GI bleed, Ruptured Ectopic Pregnancy)Other Hemorrhage (GI bleed, Ruptured Ectopic Pregnancy)

Etiology: Life threateningEtiology: Life threatening

PulmonaryPulmonary Pulmonary EmbolismPulmonary Embolism PneumothoraxPneumothorax

CNSCNS Ischemia/HemorrhageIschemia/Hemorrhage

Toxic/Metabolic DerangementsToxic/Metabolic Derangements Glucose, Electrolyte abnormalities, Ingestions, CO Glucose, Electrolyte abnormalities, Ingestions, CO

poisoning etc.poisoning etc.

Etiology: Other CausesEtiology: Other Causes

HyperventilationHyperventilation Vasovagal (Emotion, Pain)Vasovagal (Emotion, Pain) Carotid Sinus Sensitivity (Necktie/shaving)Carotid Sinus Sensitivity (Necktie/shaving) Miscellaneous ReflexMiscellaneous Reflex

Cough, sneezeCough, sneeze ExerciseExercise GI-swallowing, vomiting, defecationGI-swallowing, vomiting, defecation PostmicturitionPostmicturition Increased intrathoracic pressure (weightlifting)Increased intrathoracic pressure (weightlifting)

Hypoperfusion (Orthostasis, Anemia)Hypoperfusion (Orthostasis, Anemia)

Etiology: Other CausesEtiology: Other Causes

SeizuresSeizures NarcolepsyNarcolepsy PsychogenicPsychogenic

AnxietyAnxiety Conversion disorderConversion disorder Somatization disorderSomatization disorder Panic disorderPanic disorder Breath holding spellsBreath holding spells

Etiology: DrugsEtiology: Drugs

CVCV Bblockers, vasodilators, diuretics, Bblockers, vasodilators, diuretics,

antihypertensives, QT prolonging agents, antihypertensives, QT prolonging agents, dysrhythmicsdysrhythmics

PsychoactivePsychoactive Anticonvulsants, antiparkinson, CNS depressants, Anticonvulsants, antiparkinson, CNS depressants,

MAOI, TCA, narcotics, antihistamines, MAOI, TCA, narcotics, antihistamines, cholinesterase inhibitorscholinesterase inhibitors

Etiology: Drugs Etiology: Drugs

Other drugs to considerOther drugs to consider Drugs of abuse (THC, cocaine, etoh, heroine)Drugs of abuse (THC, cocaine, etoh, heroine) Diabetes medicationsDiabetes medications Neuropathic drugs (vincristine)Neuropathic drugs (vincristine) NSAIDSNSAIDS BromocriptineBromocriptine

Evaluation of Syncope PatientEvaluation of Syncope Patient

Rapid Assessment: If patient unstable: ABC’s Rapid Assessment: If patient unstable: ABC’s and other necessary means of stabilization and other necessary means of stabilization BUT…BUT…

Since syncope is a transient event, most Since syncope is a transient event, most patients are able to give historypatients are able to give history

Also important to talk to family members or Also important to talk to family members or other individuals at the sceneother individuals at the scene

EvaluationEvaluation

Important information to gather…Important information to gather… Abrupt or gradual onsetAbrupt or gradual onset

If it is abrupt while sitting or supine, suspicious for If it is abrupt while sitting or supine, suspicious for cardiac etiologycardiac etiology

Events prior to the syncopal episodeEvents prior to the syncopal episode Associated with exertion? Possible outflow obstructionAssociated with exertion? Possible outflow obstruction Hot environment? OrthostasisHot environment? Orthostasis Associated with Chest pain/SOB? Possible MI, Associated with Chest pain/SOB? Possible MI,

Dissection, PE, PneumothoraxDissection, PE, Pneumothorax

EvaluationEvaluation

(cont’d) Events prior to syncopal episode(cont’d) Events prior to syncopal episode Headache? Possible intracranial hemorrhageHeadache? Possible intracranial hemorrhage Abdominal Pain? r/o Dissection, Ruptured aneurysm or Abdominal Pain? r/o Dissection, Ruptured aneurysm or

Ectopic pregnancy Ectopic pregnancy Diaphoresis/lightheaded/dim vision? VasovagalDiaphoresis/lightheaded/dim vision? Vasovagal Aura? Consider seizureAura? Consider seizure

What happened during the event and how long did it What happened during the event and how long did it last?last? Tonic-clonic mvmts? Possible seizureTonic-clonic mvmts? Possible seizure Trauma from fall/ or did they pass out before they fell?Trauma from fall/ or did they pass out before they fell?

Further information to distinguish Further information to distinguish between Syncope vs. Seizurebetween Syncope vs. Seizure

Factors favoring syncope Factors favoring syncope Nausea or diaphoresis preceding spellNausea or diaphoresis preceding spell Orientation upon awakeningOrientation upon awakening Age > 45 years oldAge > 45 years old Prolonged sitting or standing prior to episodeProlonged sitting or standing prior to episode History of CHF or CADHistory of CHF or CAD

Factors favoring seizureFactors favoring seizure History of seizure disorderHistory of seizure disorder Tongue bitingTongue biting Post-ictal periodPost-ictal period LOC > 5 minutesLOC > 5 minutes Preceding AuraPreceding Aura Age < 45 years oldAge < 45 years old Observed unusual posturing/jerking or head turningObserved unusual posturing/jerking or head turning

HistoryHistory

Pertinent Past Medical HistoryPertinent Past Medical History History of Seizure disorderHistory of Seizure disorder CADCAD CHFCHF AneurysmsAneurysms Aortic StenosisAortic Stenosis GI bleedGI bleed HypertensionHypertension DiabetesDiabetes MigrainesMigraines

MedicationsMedications

Remember to get a full medication list and ask Remember to get a full medication list and ask about…about… Changes in medsChanges in meds Compliance with medicationsCompliance with medications Eating after medications (i.e. Insulin)Eating after medications (i.e. Insulin)

Physical ExamPhysical Exam

SystemSystem Pivotal FindingPivotal Finding SignificanceSignificanceVital signsVital signs Pulse rate/rhythmPulse rate/rhythm

RR and depthRR and depth

Blood PressureBlood Pressure

TemperatureTemperature

ArrhythmiasArrhythmias

Tachypnea suggests hypoxia, Tachypnea suggests hypoxia, hyperventilation or PEhyperventilation or PE

Underlying shock may be present and Underlying shock may be present and may contribute to syncope in 15-30% may contribute to syncope in 15-30% pts.pts.

Fever from sepsis may cause Fever from sepsis may cause orthostasisorthostasis

SkinSkin Color, diaphoresisColor, diaphoresis Signs of decreased organ perfusionSigns of decreased organ perfusion

Physical ExamPhysical Exam

SystemSystem Pivotal FindingPivotal Finding SignificanceSignificanceHEENTHEENT Tenderness/deform.Tenderness/deform.

PapilledemaPapilledema

BreathBreath

Signs of traumaSigns of trauma

Increased ICPIncreased ICP

Ketones for DKAKetones for DKA

NeckNeck BruitsBruits

JVDJVD

Source of cerebral emboliSource of cerebral emboli

Right heart failure from ischemia, Right heart failure from ischemia, tamponade or PEtamponade or PE

LungsLungs Breath sounds, Breath sounds, crackles, wheezescrackles, wheezes

Infection, left heart failure from Infection, left heart failure from ischemia, PEischemia, PE

Physical ExamPhysical Exam

SystemSystem Pivotal FindingPivotal Finding SignificanceSignificanceHeartHeart Systolic MurmurSystolic Murmur

RubRub

Aortic stenosis, HCMAortic stenosis, HCM

Pericarditis, tamponadePericarditis, tamponade

AbdomenAbdomen Pulsatile massPulsatile mass AAAAAA

RectumRectum Hematest stoolHematest stool Anemia, hypovolemiaAnemia, hypovolemia

PelvisPelvis Uterine bleeding, Uterine bleeding, adnexal tendernessadnexal tenderness

Anemia, ectopic, hypovolemiaAnemia, ectopic, hypovolemia

ExtremitiesExtremities Pulse equality in Pulse equality in upper extremitiesupper extremities

Subclavian steal, aortic dissectionSubclavian steal, aortic dissection

NeurologicNeurologic Mental status, focal Mental status, focal deficitsdeficits

Seizure, stroke, other primary neurologic Seizure, stroke, other primary neurologic diseasedisease

Diagnostic Studies: What to look Diagnostic Studies: What to look for…for…

12 lead EKG12 lead EKG Dysrhythmias, ischemiaDysrhythmias, ischemia

OrthostaticsOrthostatics Orthostatic hypotensionOrthostatic hypotension

CBC/Electrolytes, GlucoseCBC/Electrolytes, Glucose Anemia, metabolic abnormalities, hypoglycemiaAnemia, metabolic abnormalities, hypoglycemia

B-HCGB-HCG Pregnancy ? Normal IUP vs ectopicPregnancy ? Normal IUP vs ectopic

Diagnostic Studies: What to look Diagnostic Studies: What to look for…for…

Drug screen and therapeutic drug levelsDrug screen and therapeutic drug levels Serum etohSerum etoh ABGABG

Hypoxemia, hyperventilationHypoxemia, hyperventilation CXRCXR

Pneumothorax, dissectionPneumothorax, dissection Head CTHead CT

Check if new-onset seizure, history of traumaCheck if new-onset seizure, history of trauma

Diagnostic studies: UltrasoundDiagnostic studies: Ultrasound

Ultrasound can quickly help identify multiple Ultrasound can quickly help identify multiple causes.causes. AbdominalAbdominal

Abdominal aortic aneurysm/dissection, intraabdominal Abdominal aortic aneurysm/dissection, intraabdominal hemorrhage hemorrhage

PelvicPelvic Ectopic vs. IUPEctopic vs. IUP

CardiacCardiac Tamponade, outflow obstructionTamponade, outflow obstruction

Aortic Dissection and syncopeAortic Dissection and syncope

Ultrasound can be invaluable if you suspect Ultrasound can be invaluable if you suspect dissection!dissection! Need to rule out tamponade- the most common Need to rule out tamponade- the most common

mechanism of death in acute aortic dissectionmechanism of death in acute aortic dissection American Journal of Med, 2002: International American Journal of Med, 2002: International

registry of aortic dissection (IRAD) collected registry of aortic dissection (IRAD) collected data on 728 pts with acute aortic dissection.data on 728 pts with acute aortic dissection. Syncope reported in 96 (13%) of patientsSyncope reported in 96 (13%) of patients

Aortic Dissection and SyncopeAortic Dissection and Syncope

The study further showed that patients with acute The study further showed that patients with acute aortic dissection who had a syncopal episodeaortic dissection who had a syncopal episode Were more likely to die in the hospital (34%) than those Were more likely to die in the hospital (34%) than those

without (23% P=0.01)without (23% P=0.01) Were more likely to have tamponade (28%) vs (8% Were more likely to have tamponade (28%) vs (8%

P=0.001)P=0.001) Stroke was a more common complication (18%) vs (4% Stroke was a more common complication (18%) vs (4%

P=<0.001)P=<0.001) Experienced more neurological deficits (25%) vs (14% Experienced more neurological deficits (25%) vs (14%

P=.005)P=.005)

Aortic dissection and SyncopeAortic dissection and Syncope

Patients with proximal dissections more often Patients with proximal dissections more often had syncope than with distal dissectionshad syncope than with distal dissections

19% vs 3% P<0.00119% vs 3% P<0.001

* Keep in mind that acute paraplegia secondary * Keep in mind that acute paraplegia secondary to spinal cord ischemia occurs in dissections to spinal cord ischemia occurs in dissections involving the descending aorta and may be involving the descending aorta and may be mistaken as syncopemistaken as syncope

Aortic dissection and SyncopeAortic dissection and Syncope

Excluding those complications discussed prior Excluding those complications discussed prior (tamponade, stroke etc), syncope alone does (tamponade, stroke etc), syncope alone does not appear to increase the risk of death.not appear to increase the risk of death.

Forty-six percent of patients with syncope had Forty-six percent of patients with syncope had no explanation for their LOC and could have no explanation for their LOC and could have been caused by…been caused by… Vasovagal secondary to pain from the dissectionVasovagal secondary to pain from the dissection Direct stretching of the baroreceptors in the aortic Direct stretching of the baroreceptors in the aortic

wallwall

Admission vs DischargeAdmission vs Discharge

Treat the underlying cause, and if one is found, Treat the underlying cause, and if one is found, admit or discharge appropriately.admit or discharge appropriately.

Potential guideline to help physicians with Potential guideline to help physicians with decision making called The San Franciso decision making called The San Franciso Syncope RuleSyncope Rule

San Francisco Syncope RuleSan Francisco Syncope Rule

If the patient has any of these, they are at a high risk If the patient has any of these, they are at a high risk for a serious outcome and require admissionfor a serious outcome and require admission At the time of triage: systolic <90At the time of triage: systolic <90 Patient complaint of SOBPatient complaint of SOB History of CHFHistory of CHF Hematocrit <30Hematocrit <30 EKGEKG

Does the patient have a rhythm that is not sinus? Does the patient have a rhythm that is not sinus? Does the patient have new changes on their EKG? Does the patient have new changes on their EKG?

San Francisco Syncope RuleSan Francisco Syncope Rule

CC: : CCHF historyHF history

HH: : HHematocrit < 30ematocrit < 30

EE: : EEKG changesKG changes

SS: : SSystolic <90ystolic <90

SS: : SShort of Breathhort of Breath

San Francisco Syncope RuleSan Francisco Syncope Rule

If the patient does not meet any of those If the patient does not meet any of those criteria – the patient is at a low risk for serious criteria – the patient is at a low risk for serious outcome requiring admissionoutcome requiring admission

A study was conducted in June 00-Feb 02 A study was conducted in June 00-Feb 02 (J of (J of

EM Oct 2005)EM Oct 2005) comparing the application of this comparing the application of this rule vs physician judgment in predicting which rule vs physician judgment in predicting which patients will have a serious outcome within 7 patients will have a serious outcome within 7 days of the ED visitdays of the ED visit

San Francisco Syncope RuleSan Francisco Syncope Rule

Study (cont’d): Serious outcomes were defined as Study (cont’d): Serious outcomes were defined as MI, arrhythmia, PE, hemorrhage, stroke, death.MI, arrhythmia, PE, hemorrhage, stroke, death.

Both physicians and the SFSR were able to predict Both physicians and the SFSR were able to predict those who will have a serious outcomethose who will have a serious outcome

BUT, physicians still admitted many patients even BUT, physicians still admitted many patients even though they felt they were low riskthough they felt they were low risk

If the SFSR had been utilized, there could have been If the SFSR had been utilized, there could have been a 10% decrease in admission of the low risk group.a 10% decrease in admission of the low risk group.

Low Risk Patients & Negative ED Low Risk Patients & Negative ED workupworkup

Journal of EM 2004. A small study of 45 patients Journal of EM 2004. A small study of 45 patients conducted over a 3 month period of time. Patients conducted over a 3 month period of time. Patients presented with syncope, had a negative workup in the presented with syncope, had a negative workup in the ED and were followed up in one month.ED and were followed up in one month. If asymptomatic patients who…If asymptomatic patients who…

Denied any chest pain, abdominal pain or focal neurological Denied any chest pain, abdominal pain or focal neurological symptomssymptoms

Have acceptable vital signsHave acceptable vital signs Lack new cardiopulmonary or neurological findingsLack new cardiopulmonary or neurological findings Have normal glucose levelsHave normal glucose levels Have normal or unchanged ED tracings during their ED eval.Have normal or unchanged ED tracings during their ED eval.

Low risk patients and negative ED Low risk patients and negative ED workupworkup

Those patients that meet those criteria may not Those patients that meet those criteria may not benefit from hospitalization.benefit from hospitalization.

Considering hospitalization is not completely benign Considering hospitalization is not completely benign and may pose unforeseen risk to otherwise healthy and may pose unforeseen risk to otherwise healthy patients due to…patients due to… Medication changes and errorsMedication changes and errors InstrumentationInstrumentation Risk of nosocomial infectionsRisk of nosocomial infections Forced bed rest (risk of DVT, PE)Forced bed rest (risk of DVT, PE)

SummarySummary

There are many causes of syncopeThere are many causes of syncope Be vigilant in ruling out the life-threatening Be vigilant in ruling out the life-threatening

ones!ones! Use the ultrasound machineUse the ultrasound machine Take into account the risks of hospitalizationTake into account the risks of hospitalization

SourcesSources Quinn, Stiell, McDermott, Kohn, Wells: The San Quinn, Stiell, McDermott, Kohn, Wells: The San

Francisco Syncope Rule vs physician decision Francisco Syncope Rule vs physician decision making. Am J Med 2005; 23, 782-786.making. Am J Med 2005; 23, 782-786.

Nallamothu, Mehta, Saint: Syncope in Acute Aortic Nallamothu, Mehta, Saint: Syncope in Acute Aortic Dissection: Diagnostic, Prognostic and Clinical Dissection: Diagnostic, Prognostic and Clinical Implications. Am J Med 2002; 113, 468-471.Implications. Am J Med 2002; 113, 468-471.

Junaid, Dubinsky: Establishing an approach to Junaid, Dubinsky: Establishing an approach to syncope in the emergency department. J EM; 15, syncope in the emergency department. J EM; 15, 593-599593-599

Rosen’s Emergency Medicine: Concepts and Clinical Rosen’s Emergency Medicine: Concepts and Clinical Practice. Chapter 20. Syncope.Practice. Chapter 20. Syncope.