Syncope

Question 1

DDx for syncope:

Answer 1

Vagal
- Situational (distress, vomit, instrumentation etc.)
- Carotid sinus stimulation
- Orthostatic
Cardiac
- Arrhythmia
- Structural (HOCM, MI, AS/ other valve, CM)
- Endocarditis/ myocarditis
- Tamponade
Vascular
- PE
- Dissection
- AAA
- Haemorrhage (incl. ectopic)
Neuro
- Seizure
- SAH
- SDH
- Vertebrobasilar insufficiency (TIA)
- Subclavian steal
Endocrine
- Hypoglycaemia
Psychiatric
- Somatisation
Tox
- Envenoming
- Vasoactive drugs

Question 2

HISTORY in the work up of syncope:

Answer 2

HISTORY
Event
- Situation (eg. exertional, stressor, standing up, hot, at rest)
- Preceding symptoms (aura, dizzy, CP, abdo pain)
- Duration of LOC
- Incont/ tongue bite during LOC
- Rapidity of coming-to
- Residual symptoms

Corroborate with bystanders

PMHx
- PMHx (CCF, IHD, valve, AAA, FHx SCD, intracranial)
- Medications

Question 3

‘High risk’ features in syncope:

Answer 3

Validated tools: San Francisco (CHESS), Boston, ROSE (BRACES)

• ‘CHESS’
  –> San Fran rule
  –> CCF, HCT <30%, ECG abn, SOB, SBP <90 at triage
• Elderly
• Cardiac disease
  –> Hx known, IHD symptoms, new ECG abnormality etc..
• FHX sudden death
• Unwitnessed
• Exertional
• At rest
• Recurrent
• Persisting abnormal vitals
  etc.

Question 4

San Francisco Syncope Rule:

Answer 4

‘CHESS’

Congestive heart failure
HCT <30%
ECG abnormal (change, or non-sinus)
SOB
SBP <90 (at triage- ie. persistant)

If 0 = low risk of serious event in 7 days, consider DC.
If ANY positive = not low risk. Admit.

Question 5

Boston Syncope Rules

Answer 5

Question 6

Who can be safely DC from ED after a syncope?

Answer 6

1- Those without any high risk features (as above)
PLUS
Normal work up (thorough history, examination and ECG at minimum).

2- When the diagnosis is clearly dehydration or vasovagal, regardless of risk factors (as per Boston)

Question 7

ECG in syncope:

Answer 7

‘A2B2C, W and Long QT

ACS
ARVD
Blocks (AV)
Brugada
Cardiomyopathy (HOCM, LVH)
WPW
Long QT