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New Syncope Recommendations

9/7/2017

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2017_Guidelines.pdf
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​In-line with the month’s cardiology theme, this note from the TR desk will discuss the evaluation of syncope, and the brand new (2 days young) ACCF/AHA Guidelines for the Evaluation and Management of Patients With Syncope.
 
TL;DR: Watch Sonal’s syncope lightning rounds, and consider using the San Fran or Boston (both links) syncope rules. Use the FREE DOTPHRASE to help remind yourself of syncope patients who may required admission.
 
The 2017 recommendations are the most evidence-based guidelines yet for the evaluation of syncope, and based on an extensive literature review and committee discussion which included emergency medicine physicians, ACEP, and SAEM! Studies report an estimated prevalence of a single episode of syncope at 19% of the population. Females have a higher prevalence of syncope, and those with chronic cardiac and vascular issues are more likely to have recurrent syncope. The most common cause of syncope is unknown in most cases (37%), followed by Reflex Syncope (21%), Cardiac Syncope (9%) and Orthostatic Hypotension (9%).
 ​
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The recommendations include a relatively worthless chart (above) showing how to initially evaluate a patient with syncope, recommending a detailed history and examination including orthostatics and evaluation for new murmurs, and a neurological exam. There is also Level B evidence that syncope patients should be evaluated with an EKG (This is a level A recommendation from ACEP). Given Cardiac Syncope has a high risk of recurrence and death, this seems appropriate. The article goes on to recommend targeted lab testing in any patient where the initial evaluation and diagnosis is not crystal clear. If you were here for Dr. Batra’s excellent discussion on syncope last year, none of this is surprising to you.
 
The recommendations also discuss the use of many of the current Syncope Risk Scores, including the San Francisco Syncope Rule, Boston Syncope Rule, and Del Rosso (All three of these have Negative Predictive Values of 99%). This is probably the most important part, as we need to determine which patients are safe to discharge, versus those who should be admitted. When looking across all three rules, a few bit picture items come out; abnormal EKGs, a history of CHF or heart disease, age >65, and syncope either without a prodrome or while supine, are all concerning for higher-risk Cardiac Syncope. Additionally, we should consider alternative causes of syncope, including pulmonary embolism (DO NOT bring up the PESIT Trial), pregnancy, anemia/GI bleeding, and neurologic causes. As such, you can use the dotphrase below to help remind yourself of these potential causes, and reasons to consider admission for monitoring, Holter monitor placement, and potentially further workup.

Dotphrase/Macro

Pt here with syncope/near syncope. Seizure less likely given history and exam. No neurologic deficits on exam indicating a stroke, and no signs of head trauma or injury. Given no signs of trauma or neurologic deficit, I will withhold further imaging of the head per ACEP Choosing Wisely Recommendations. Additionally, ACEP clinical policy on syncope evaluation recommends laboratory testing and advanced investigative testing such as echocardiography or cranial CT scanning need not be routinely performed unless guided by specific findings in the history or physical examination.
 
Patient’s history includes _ prior syncopal events, _ CAD, _ DVT/PE, _ seizures. Cardiac evaluation today shows _ murmur, _ JVD, _ peripheral pulses and _ lower extremity edema. EKG today _ without signs of Brugada or QT shortening or prolongation.  _ PE risk factors. Neurologically _. Blood glucose _, _signs of hypoxia during event or currently, and _ intoxication complicating the patient’s presentation. Given this, the patient’s episode _.
Risk Factors for Serious Cause: older age, pre-syncopal exertion, history of cardiac disease including heart failure, family history of sudden death, recurrent episodes, recumbent episode, prolonged loss of consciousness, chest pain or palpitations. Age >65, and Hct <30%
 
San Francisco Syncope Rule (.ekmdmsanfran)CHF History
Hct <30%
EKG Abnormality
SOB
SBP < 90 mmHg at triage
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The Quick Confusion Scale: An alternative to the Mini-Mental Status Exam

5/3/2017

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​The QCS can be administered more quickly than the MMSE, and is easier to administer in the ED
validation_qcs.pdf
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Status Epilepticus

1/18/2017

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Status epilepticus is a common neurological emergency when a patient has a prolonged seizure or a series of seizures with incomplete return to baseline. The approach to status epilepticus has focused on early seizure termination, and rapid escalation of care to include general anesthesia when needed. 
​
Status Epilepticus
: A prolonged seizure or multiple seizures with incomplete return to baseline. 

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Bupivacaine vs Lidocaine: Which is faster?

1/7/2017

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Bupivacaine and lidocaine are often used concurrently, in theory, to combine the more rapid onset of lidocaine and the longer duration of bupivacaine. However, multiple studies, including a 1996 Journal of Podiatric Medicine article and a 2013 Canadian Journal of Plastic Surgery study have found no statistical difference between the anesthetics with regard to onset of action. 
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lido_v_bupivicaine.pdf
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qSOFA & The New Sepsis Definitions

6/1/2016

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qSOFA was introduced as part of the Sepsis-3 guidelines published in February 2016. SOFA is a well-known scoring system used in the ICU setting, and qSOFA is a simplified version that uses only 3 clinical criteria; altered mentation, tachypnea, and hypotension. 

Why the change; the current SIRS Criteria is less sensitive and specific than the SOFA score. Utilizing 2 or more SIRS criteria was felt to be unhelpful by the 2016 task force,

Instead, qSOFA utilizes the most important criteria for those at risk for poor outcomes from sepsis. 

Looking forward, remember that qSOFA is not a screening tool for sepsis, but a predictor of poor outcomes to help identify those patients who need additional providers and immediate interventions. 

To learn more about the new JAMA Third International Consensus Definitions for Sepsis and Septic Shock, read the article, or listen to the FOAMcast on Sepsis Redefined. 
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Naproxen With Cyclobenzaprine, Oxycodone/Acetaminophen, or Placebo for Treating Acute Low Back Pain

1/6/2016

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According to this new article from JAMA, the addition of Percocet or Flexeril to Naproxen does not improve functional outcomes in acute low back pain. The article compared functional outcomes in lower back pain at 1 and 3 weeks between Naproxen, Flexeril, and Percocet. Via a randomized, double-blind study in NYC, 323 patients were randomized to Naproxen + Placebo, Naproxen + Flexeril, and Naproxen + Percocet. Using an improvement in the Roland-Morris Disability Questionnaire (RMDQ), the study found that adding cyclobenzaprine or oxycodone/acetaminophen to naproxen alone did not improve functional outcomes or pain at 1-week follow-up. These findings do not support use of these additional medications in this setting.
Full Article
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CT only rule-out of subarachnoid hemorrhage?

12/7/2015

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Can a CT read within 6 hours of headache onset can rule out SAH without the need for a lumbar puncture? This study found a 99% NPV of staff-read CTs in 11 non-academic centers with a 1/15,200 missed aneurysmal SAH. This study did not discuss the accuracy of resident or emergency medicine interpretations of CT scans. 

A multicenter, retrospective study of 11 non-academic centers. Included patients older than 16, with acute-onset headache of known duration without focal deficits or altered mental status. To be included, patients had to undergo a CT in <6 hours from headache onset and a lumbar puncture >12 hours from headache onset. 760 patients were included with 52 positive CSF findings. On review of CT imaging, 51 were considered negative, and only one perimesencephalic nonaneurysmal SAH was found, and no readmissions due to SAH. 
Full Article
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HINTS  Screen for Stroke in Acute, Continuous Vertigo and Dizziness

12/3/2015

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Adapted from a presentation by Ty Nichols, 12/2/2015
Dizziness can be difficult to assess in the ED given the vast range of etiologies and varying ways patients interpret their symptoms. Additionally, not all patients with emergency conditions will present with obvious focal deficits. A clinical decision making rule (HINTS) can help to more rapidly identify stroke patients to initiate acute therapies faster. The HINTS rule outperforms ABCD2  for stroke diagnosis in the ED when performed by qualified practitioners in patients with Acute Vestibular Syndrome. 
Link to 8 minute how-to video
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Full Article
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San Francisco Syncope Rule

11/30/2015

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A mechanism to risk stratify patients presenting with syncope
The SFSR is criticized as being unsafe given a high miss rate (pooled sensitivity of 86%). Notably, there is one patient in the original trial who was SFSR negative and subsequently died (cardiac arrest after inpatient hospital discharge).

Exclusion Criteria
  • Trauma-related loss of consciousness
  • Alcohol-related loss of consciousness
  • Drug-related loss of consciousness
  • Definite seizure
  • LOC associated with an altered level of consciousness or persistent new neurologic deficits did not meet operational definition of syncope and were excluded 
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Full Article
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Evidence-Based Pain Management

11/21/2015

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Tainter CR. An evidence-based approach to traumatic pain management in the
emergency department. Emerg Med Pract. 2012 Aug;14(8):1-26. Epub 2012 Jul 20.
PubMed PMID: 22916717.
http://www.ncbi.nlm.nih.gov.proxygw.wrlc.org/pubmed/22916717
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This site is independently owned and operated and not affiliated with the George Washington University, George Washington University Hospital, or Medical Faculty Associates. All information on this site is the opinion of the author alone and in no way should be seen to represent the views of the George Washington University, George Washington University Hospital, or Medical Faculty Associates. The information on this page is for personal use only and should not be see as medical advice or used directly for patient care. The author provides no guarantee of the accuracy of the information provided on this page. ​

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