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Lightning Rounds: Syncope

8/17/2016

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Appropriate Syncope Workup

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  • ​EKG
  • Electrolytes: Not predictive of poor outcomes, and should not be part of your workup without a clinical suspicion.  
  • Head CT: Only useful in those with neurologic deficits or focal symptoms during the syncopal episode, or those with trauma. ACEP Choosing Wisely. 
  • CBC:  Anemia is predictive of poor outcomes, and patients should be evaluated if at risk for anemia (elderly, females with heavy menses, GI bleeds, or a concerning history). Utilized in the San Francisco Syncope Rule. 

EKG Abnormalities in Syncope

  • Tachyarrhythmias
  • Bifascicular block or conduction delay
  • Bradycardia/AV block
  • Prolonged or shortened QT interval
  • Brugada pattern (RBBB with ST elevation)
  • WPW
  • Hypertrophic cardiomyopathy: sharp, deep Q waves in lateral leads, 
  • Ischemia
  • ARVD: Epsilon wave or negative T waves in precordial leads: Right sided cardiomyopathy, Typically presenting in young patients with a history of syncope. 
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Epsilon Wave

Disposition of Syncopal Patients

PictureACEP Risk Factors in Syncope
  • Suspected or diagnosed cardiac cause of syncope
    • Abnormal EKG
    • History or cardiac disease (CHF, low EF, new murmur)
    • Exertional Syncope
    • Sudden onset without a prodrome
  • Anemia or other lab abnormalities
  • ACEP Clinical Policy for Syncope Management


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Altered Consciousness & Coma

12/27/2015

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Adapted from Rosens, chp 16. 

Little Old Lady Workup (LOL)

Testing to consider in an elderly patient with altered mental status
ABG: hypoxia, CO2 retention, SOB
BMP/CMP: electrolyte abnormalities, hepatic encephalopathy
UA: infection, DKA, ingestion
PT/INT: hemorrhage, anemia, hypercoagulable
Lactate: ketotic state, ingestion, ischemia
TSH: thyroid storm, hypothyroid
Cardiac Enzymes: MI, ischemia, cardiogenic shock
CXR: infection, pneumothorax, CHF
CT head: hemorrhage, mass
MRI: edema, mass, ischemia
CTA: pulmonary emboli, aortic dissection
LP/CSF: infection, ICP

Confusion

Organic Confusion

Acute onset confusion with fluctuating consciousness and poor recent memory, possibly associated with focal deficits, hallucinations or abnormal vital signs. 

Functional Confusion

Chronic or slow-onset, normally alert and oriented, with some agitation or anxiety, possibly auditory hallucinations and normal vitals, no focal deficits, and illusions or delusions. 
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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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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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