approach to syncope

syncope

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.

syncope

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