Management of Syncope in the Emergency Department

Jonathon M. Sullivan MD, PhDHonorary Professor Syncopatus Emeritus Bullshitticus Maximus DuplicitusDepartment of Emergency MedicineWayne State University

LIMITS AND BOUNDARIES

Won’t talk about pediatric syncope What are these “children” things I keep

hearing about? Won’t parade a bunch of papers

You’re welcome This isn’t an EKG conference

Leave it to the Berkserker Outpatient workup of syncope

About 50% Voodoo anyway

CASE STUDY: 48 yo maladjusted WM EP w. no PMH has

witnessed LOC while standing at pt bedside (work hour 13), sustaining head injury.

Brief prodrome of fatigue, stress, dizziness, sandwich-related thoughts.

Overcaffeinated, up for 16.5 hours, minimal food or H2O due to workload.

No pulse palpated for about 5s, CPR briefly initiated.

Return of consciousness at 10-20 secs: Slightly confused but appropriate:

“Get the f**k up off me.” Exam shows a poorly-groomed middle-aged

hump with normal VS, congenital anisocoria (no burr holes, please), small occipital scalp lac, CTA, RRR, normal neuro, pulse ox 99%.

QUESTIONS:

What are the immediate treatment/stabilization priorities?

Is this syncope or something else? Is the differential for syncope

Quite Extensive, Humongoid, or Galactically colossal?

What are the relevant historical and physical exam findings?

What tests, if any, would you order on this doofus?

What is the best way to make this guy somebody else’s problem?

IMMEDIATE PRIORITIES: This is 2009:

Check insurance status Register patient Print stickers Click 29-minute box Use foam on entering module

Handwashing Gestapo are everywhere Approach the customer with a bright DMC

smile. ABCs, monitor, O2, IV C-spine precautions Check glucose?

WAS THIS SYNCOPE?

If so, why? If not, why not?

WHAT IS SYNCOPE?

συγκοπή – “syncopa” to cut off. Cut off what?

Greek guys didn’t say.

Syncope = transient loss of consciousness and postural tone with rapid onset and spontaneous, prompt and complete recovery without intervention.

So: Did our patient have syncope?

WHAT COULD CAUSE SYNCOPE? Anything that causes a sudden, transient

loss of consciousness can cause syncope. Assumes that we know what consciousness is.

Consciousness can report only its presence, not its absence.

But that’s another lecture. In most people, the organ of consciousness

is the brain. Therefore, syncope is a manifestation of

brain (end-organ) dysfunction. At the neurological level, only two things

can cause syncope: Transient brainstem dysfunction at the level of

the RAS; or Transient bilateral cerebral dysfunction.

This is a tall order! What could do this?

WHAT COULD CAUSE SYNCOPE? NEUROGENIC:

WHAT COULD CAUSE SYNCOPE? TOXIC-METABOLIC

ALCOHOL SEDATIVE-HYPNOTICS (HERON, ETC) SYMPATHOMIMETICS (CAINE, CRANK, ETC) AXE BODY SPRAY AND OTHER WHIFFERS GLUCOSE SODIUM CALCIUM POTASSIUM HISTAMINE, ALLERGIC REACTIONS HYPOXIA

WHAT COULD CAUSE SYNCOPE? CARDIOVASCULAR

The critical organ system… …that constantly pumps… …the essential good stuff… …that makes the brains go.

SUTTON’S LAW: “That’s where the money is.”

WHAT COULD CAUSE SYNCOPE? CARDIOVASCULAR:

Arrhythmias Bradycardias

Carotic sinus sensitivity Sick sinus syndrome Heart blocks Pacemaker malfunction

Tachycardias Malignant “stable” Think long QT, Torsades, SVT, VTach

Obstruction to flow Left-sided: Hypertrophic cardiomyopathy, left atrial myxoma, aortic stenosis,

mitrial stenosis Right-sided: PE, pulm htn, pulmonic stenosis, right atrial myxoma Valvulopathy PE

Vascular Catastrophes Dissection Ruptured AAA

Vasomotor Orthostasis and hypovolemia Autonomic dysfunction Situational syncope Anaphylaxis—bee stings, scromboid, drug rxs, etc. “Vasovagal syncope”

WHAT COULD CAUSE SYNCOPE?

VASOVAGAL One of the most notorious wastebasket

diagnoses in clinical medicine. Derives from

An ancient Greek work meaning “doctor has no f**k’n clue why you dfo’d.”

More general (and therefore, usually, more correct) term is neurocardiogenic syncope.

Proximate cause is actually increased vasomotor tone and cardiac contractility

WHAT COULD CAUSE SYNCOPE?

VASOVAGAL Can occur in any susceptible patient when

precipitated by any event which causes: Venous pooling Increased sympathetic tone May be both caused (pooling) or

exacerbated (enhances reflex) by alcohol. Patients are fine immediately after

precipitant (such as standing), then dfo as reflex kicks in.

WHAT COULD CAUSE SYNCOPE?

VASOVAGAL

VENOUSPOOLIN

G

INC SYMP’TI

CTONE

BETZOLD-

JARISH REFLEX

BRADYCARDIA,

VENODILATION,

DFOALL KINDSA

STUFF!

WHAT COULD CAUSE SYNCOPE?

VASOVAGAL

WHAT COULD CAUSE SYNCOPE?

VASOVAGAL High-Risk Diagnosis. Why?

Because this is what you’ll put on the chart when you send that guy home with the ruptured AAA.

Don’t make the diagnosis of “vasovagal” unless you have clear historical and exam findings to support it.

In fact, try not to make this diagnosis at all. There’s nothing wrong with a final impression of “syncope.”

“You don’t have to make the right diagnosis. You just have to make the right decision.”

El-Rod

WHAT COULD CAUSE SYNCOPE? SITUATIONAL SYNCOPE

WHAT COULD CAUSE SYNCOPE? SITUATIONAL SYNCOPE

Fear, pain, stress Hunger Unbearable sights

Blood, vomit, filth Violence, death Fat people in spandex

Elvis, Hitler, Brad Pitt Urination, defecation, sneezing, coughing,

swallowing Decreased venous return/Valsava BJ reflex?

WHAT COULD CAUSE SYNCOPE? BY FREQUENCY (fr Henry et al):

COMMON: VT, SVT Hypovolemia: bleed-ING from AAA,

ectopic, GIB, etc Vasovagal Situational: cough, micturition,

defecation Drug-induced – usually cardioactive

agents

WHAT COULD CAUSE SYNCOPE? BY FREQUENCY (fr Henry et al):

LESS COMMON: PE Heart block Valvulopathy (stenosis) MI Pacemaker malfunction SAH Psychogenic Bradycardias Psychogenic

WHAT COULD CAUSE SYNCOPE? BY FREQUENCY (fr Henry et al):

RARE (BUT IMPORTANT): Aortic dissection Basilar migraine/TIA Trigeminal or glossopharyngeal

neuralgia Sublcavian steal Pulmonary hypertension Atrial myxoma

WHAT COULD CAUSE SYNCOPE? SULLYDOG’S BOTTOM LINE:

Toxic-metabolic – not unheard-of, especially with cardio/vasoactive agents, but relatively uncommon

Neurogenic – extremely uncommon, especially in the absence of persistent neurologic symptoms or neuro findings

Cardiovascular – Sutton’s law applies.

WHAT HISTORICAL AND EXAM FEATURES ARE IMPORTANT? ALL OF THEM. SERIOUSLY.

H&P is the key to risk stratification in syncope. HISTORY-Use eyewitnesses if available

Duration of LOC Possible precipitants, prodrome Convulsions – not all that convulses is seizure Trauma Seated vs. standing Disorientation after ROC PMH, Medications, All, SHx, FHx

Focus on hx of cardiovasc disease (esp CHF), vasoactive meds, cns agents, diuretics, meds for ED, FHx of sudden death.

WHAT HISTORICAL AND EXAM FEATURES ARE IMPORTANT? EXAM:

They don’t call ‘em “vital signs” for nuttin’. Orthostatics—fuggedaboudit.

No agreement on numbers; nobody does them right, especially in ED.

Sens/Spec totally suck ass. Just think about it:

Syncope is usually cardiovascular/vasomotor Orthostasics, if properly done and if positive, suggest either

hypovolemia (easily detected with history or other exam findings) or a cardiovascular/vasomotor cause.

So orthostatics help us make better decisions…how? Thanks for playing.

Trauma-CHI, tongue biting, C-spine Signs of CHF—big mortality correlation Abdominal/rectal: Tenderness, occult blood, Big Red. Neuro: absence of findings strongly argues against

neurogenic syncope.

WHAT TESTS WOULD YOU ORDER ON THIS DOOFUS? Accu-check? Lytes, BUN, Cr/gluc, Ca, Mag, Phos,

AST, ALT, Amylase, Lipase, TFTs, PT/PTT, UA, UDS, SDS, Lactate, Osms? Right?

CT of the Brains? EKG? Chest x-ray? Orthostatics? Other?

WHAT TESTS WOULD YOU ORDER ON THIS DOOFUS? Number One Rule:

Use your history and physical to guide testing.

What a concept, huh?

WHAT TESTS WOULD YOU ORDER ON THIS DOOFUS? EKG

Low yield, but Highly specific when positive Cheap, noninvasive, makes you look very doctor-

y. Arrhythmias, blocks, pre-excitation syndromes, long

QT, Brugada, MI, LVH, etc. Monitor

Oh, for crying out loud. Why wouldn’t you? May detect badness not seen on 12-lead

snapshot 4 factors suggest benefit of extended monitoring

Old dudes, heart disease, nonsinus rhythm on EKG.

WHAT TESTS WOULD YOU ORDER ON THIS DOOFUS? THE OBLIGATORY EKG SECTION

WHAT TESTS WOULD YOU ORDER ON THIS DOOFUS? THE OBLIGATORY EKG SECTION

WHAT TESTS WOULD YOU ORDER ON THIS DOOFUS? THE OBLIGATORY EKG SECTION

WHAT TESTS WOULD YOU ORDER ON THIS DOOFUS? THE OBLIGATORY EKG SECTION

WHAT TESTS WOULD YOU ORDER ON THIS DOOFUS? THE OBLIGATORY EKG SECTION

WHAT TESTS WOULD YOU ORDER ON THIS DOOFUS? Rapid Glucose

Who gets syncope from hypoglycemia? Nobody, that’s who.

Remember the definition of syncope: Syncope = transient loss of consciousness and

postural tone with rapid onset and spontaneous, prompt and complete recovery without intervention.

How many hypoglycemics present like this? Test is cheap and safe, but diagnostic yield

approaches zero. Absolute indication:

Attending tells you to get it.

WHAT TESTS WOULD YOU ORDER ON THIS DOOFUS? OTHER LABS

Yield is extremely low, unless used to confirm specific suspicions raised by exam. Routine use is not recommended anywhere in the current literature. Caveats: All women are pregnant.

All pregnant women have ectopics. Hct < 30% predicts adverse events.

Of course, so does syncope.

d-dimer in suspected PE w. syncope is loser-ness. If you suspect PE + syncope, image.

WHAT TESTS WOULD YOU ORDER ON THIS DOOFUS? IMAGING

WHAT TESTS WOULD YOU ORDER ON THIS DOOFUS? IMAGING

ACEP: “There is no evidence to suggest that routine screening of syncope patients with advanced imaging (such as CT), functional echo, or EP testing is indicated.”

No neuro findings on H&P + no CHI = no CT. Echo indicated only in patients with cardiac

disease, abnormal EKG, suspected aortic stenosis.

Consider rapid US to screen for AAA in selected patients.

HOW CAN WE MAKE THIS GUY SOMEBODY ELSE’S PROBLEM? SEVERAL QUESTIONS OBTAIN:

Which patients with syncope will croak soon? REALLY soon: admit KINDA soon: close followup.

Or admit. Whatever keeps your undies dry.

Which patients with syncope need an outpatient workup, and what kind of workup is that?

Which patients with syncope, if any, need to just get on with their lives?

HOW CAN WE MAKE THIS GUY SOMEBODY ELSE’S PROBLEM? THE NACHRUL HYSTERY OF SYNCOPE

PROGNOSIS EXCELLENT NOT SO MUCH

HOW CAN WE MAKE THIS GUY SOMEBODY ELSE’S PROBLEM? THE NACHRUL HYSTERY OF SYNCOPE

Actual data: Pts with cardiovascular cause have

“strikingly higher” incidence of sudden death

Pts with CHF have high mortality whether or not the CHF “caused” the syncope Translation: CHF is bad.

Age > 65 = high mortality. (Ya think?) Abnormal EKG is NFG.

HOW CAN WE MAKE THIS GUY SOMEBODY ELSE’S PROBLEM?

ACEP HIGH-RISK / ADMISSION FACTORS: “Older age” and associated

comorbidities Hct < 30 History or presence of CHF, CAD, or

structural heart disease

HOW CAN WE MAKE THIS GUY SOMEBODY ELSE’S PROBLEM? THE CHESS RULE (San Francisco Rule)

CHF – pre-existing or new finding Hematocrit < 30% ECG Abnormality Shortness of breath SBP < 90 mmHg on arrivall

Initial Validation Set promising Followup studies: not so much

CHESS seems to be better at telling you who to bring in than who to send home

HOW CAN WE MAKE THIS GUY SOMEBODY ELSE’S PROBLEM? OTHER “DECISION RULES”

Boston Syncope Rules Remains to be validated 25 frippin’ criteria! Mnemonic:

HOW CAN WE MAKE THIS GUY SOMEBODY ELSE’S PROBLEM? WHO CAN GO HOME?

Patients who don’t need to be admitted. Young and otherwise healthy, no major

comorbidities No neuro findings No cardiovascular history or findings, normal EKG No evidence of bleedING, guaiac neg, Hct>30 (if

checked) Targeted studies (eg, CTPA, US for ectopic, LP for

SAH) negative Good followup Sullydog

WHAT HAPPENED TO SYNCOPE GUY?

WHAT HAPPENED TO SYNCOPE GUY? EKG negative Head CT negative Labs negative Serial trops negative Perfusion stress negative Attitude negative No additional episodes 1-year outcome pending

IS OUR DOCTORS LEARNING?

LET’S REVIEW, SHALL WE? Syncope is a sudden, transient, self-limited loss

of awareness and postural tone caused by global (not focal) dysfunction of the consciousness organ. In most of us, that’s the brain.

Neurogenic and metabolic causes are very rare. Cardiovascular and vasomotor causes are very

common. Risk stratification and indications for admission

and testing come almost exclusively from H&P.

Aside from Hct, routine lab tests are just about worthless.

IS OUR DOCTORS LEARNING?

LET’S REVIEW, SHALL WE? Routine imaging is very low yield.

Targeted imaging is useful. Admission criteria:

Any Sick Old Geez with: Heart Dis-eeZ Goofy EKG-eeZ Low BP-eeZ Suckin’ Wind/Wh-eeZE, or Low CBC-eeZ.

Now THAT’s a mnemonic.

IS OUR DOCTORS LEARNING?

LET’S REVIEW, SHALL WE? The Sullydog Admission Rule:

Old + Syncope = Admit. May not meet interqual admission criteria. Ask me later what I think about interqual

admission criteria. Lie to get them admitted if you have to. (Sullydog is a moral relativist.)

Insert Heated Argument Here.

IS OUR DOCTORS LEARNING?

LET’S REVIEW, SHALL WE? Discharge Criteria:

Patient does not require admission.

VERY FUNNY