approach to Syncope patient in ED
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SyncopeAl Yaqdhan Al Atbi, MD
EM Resident
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Outline
• Introduction• Importance• Pathophysiology • Etiology and DDx• Approach to a patient presented with syncope• Disposition
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Introduction
• Syncope or Fainting:– a transient loss of consciousness, associated with
loss of postural tone, with spontaneous return to baseline neurologic function requiring no resuscitative efforts.
• Near-syncope:– a premonition of fainting without loss of
consciousness
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Definition
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Why it is Important• accounts for 0.8% of ED visits
• prevalence in the general population is 19%.
• Most causes of syncope are benign and have favorable outcomes.
• Recurrence of syncope may be as high as 50% and is not correlated with age or sex.
• The clinical examination (history and physical examination) alone can suggest the diagnosis in 45% of cases
• The overall U.S. medical cost of syncope is estimated at $2.4 billion annually
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Pathophysiology
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Etiologies
• Common causes according to Framingham Heart Study:– Vasovagal (reflex mediated, 21%)– cardiac (10%)– orthostatic (9%)– Medication related (7%)– Neurologic (4%)– unknown (37%).
After ED investigation, the unknown proportion may be 50% to 60%.
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VASOVAGAL AND NEURALLY/REFLEX-MEDIATED SYNCOPE:
• In appropriate vagal and sympathetic tone– associated with inappropriate vasodilatation,
bradycardia, or both– lightheadedness, with or without nausea, pallor,
and/or sweating, and an associated feeling of warmth
• A slow, progressive onset with associated prodrome suggests vasovagal syncope.
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• Exposure to certaine trigger may cause it.. Example:
• unpleasant sight, sound, or smell• Fear• severe pain• emotional distress• instrumentation
Situational syncope occurs during or immediately after coughing, micturition, defecation, or swallowing.
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PSYCHIATRIC DISORDERS
• Organic causes should be rolled out first• 40% vasovagal syncope & 62% unknown• Most common Dx:– generalized anxiety disorder and major depressive
disorder
• Young> elderly
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NEUROLOGIC SYNCOPE
• Rare• Patients with loss of consciousness with
persistent neurologic deficits or altered mental status do not have true syncope.
• Subclavian steal syndrome• Seizure
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History
• Age• Syncopal attack:– Witnesses/unwitnessed– Onset , duration , recovary– Prior to attack– Attack– postsyncopal events– Associated symptoms
• Past medical hx• Medication HX
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• Carotid Massage: Carotid sinus Syndrome• Hyperventilation Maneuver psychiatric (anxiety-provoking)
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Disposition
• Inpatient:– If life threaten condition detected– Farther workup for high risk patient
• Out patient:– Low risk patients
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Take Home Message
• Syncope is a common presentation in ED.• It can indicate for a life threaten conditions.• The ED evaluation of syncope is often
inconclusive
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References
• Tintinalli’s• Rosen
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