In a patient who faints, we need to consider both the cause and the consequences, which means running through all body systems–paying special attention to the CARDIOVASCULAR system.
A
- C-spine injury
B: CHEST
- Collapse lung (pneumothorax) from rib fracture
C: CARDIOVASCULAR
- Cardiac arrhythmia: Heart rate (brady/tachyarrhtymias) Electrical (short PR, prolonged QT, trifascicular block) A R-wave (cardiomyop) Tension (HOCM) ST changes (PE, ACS, Brugada)
- Around heart: pericardial effusion
- RV strain: PE
- Dysfunctional LV: MI, CHF
- Incompetent valve, eg aortic stenosis
- Outflow dissection
- Volume depletion
- Abdominal bleed as cause or consequence of fall
- Soft tissue bleed, e.g. AAA
- Child-bearaing ectopic
- Urticaria: anaphylaxis
- Lactate: sepsis
- Addisonian
- Rx
D: NEURO
- Neuron: differentiate syncope from seizure
- RBC bleed as cause or consequence of syncope
E: ENDO
- Electrolyte: hypoglycemia
F: PELVIS
- Ectopic
G: ABDOMINAL
- A: liver injury
- O: splenic injury
H: HEME
- H: ANEMIA
INTOX
- Ingest: etoh
- Treat: hypoglycemics, antihypertensives, anticoagulants, sedatives, QT prolonging, diuretics
- OTC: NSAIDS and GI bleed
- X poison: carbon monoxide
J: joints, skin, bones
- abraisions, lacerations, fractures, soft tissue injuries
Putting this together, an assessment of syncope includes
- A: clear C-spine
- B: r/o pneumothorax or other cause of hypoxia
- C: get ECG, r/o pathologies of rhythm/pump/volume/tone
- D: differentiate syncope from seizure, assess for intracranial injury
- E: check glucose
- F: r/o pregnant
- G: examine abdomen
- H: consider CBC
- I: consider meds/drugs/toxins, especially in elderly
- J: r/o extremity injuries
Syncope can be a symptom of shock, requiring aggressive treatment. On the other end of the spectrum, many patients with syncope can be cleared and discharged after a good history, physical, ECG +/- beta for women of child-bearing age. Patients at higher risk might need further labs/imaging to r/o more serious causes of syncope (e.g. Dimer/CT chest r/o PE, serial trop r/o MI) or complications of syncope ( Xray +/- CT r/o c-spine or hip fracture; CT r/o intracranial/intra-abdominal), or admission for further investigations (e.g. cardiac monitoring for arrhythmia, echo for valvulopathy/cardiomyopathy). The San Francisco Syncope rule aims to catch these more serious causes of syncope with high risk “CHESS” features: CHF history, Hct <30, ECG abnormalities, Systolic BP <90.