SYNCOPE

Question 1

Critical DDx

Answer 1

CARDIOVASCULAR:
Lethal dysrhythmia
Structural heart disease (critical aortic stenosis or hypertrophic cardiomyopathy)
Pulmonary embolism
Thoracic aortic dissection

TRANSIENT OCCULT SHOCK:
Sepsis
Ruptured ectopic pregnancy
Gastrointestinal bleeding
Ruptured abdominal aortic aneurysm

NEUROLOGICAL:
Spontaneous sentinel subarachnoid hemorrhage not related to trauma
Transient brainstem ischemic attack

Question 2

DDx

Answer 2

CARDIAC (10%):
-Structural: outflow obstruction (AS, HOCM), -MI
-Dissection
-Cardiomyopathy
-PE
-Dysrhythmias

REFLEX (VAGAL) MEDIATED:
Vasovagal (21%)
Situational:
-cough
-micturition
-defecation
-swallow
-neuralgia
Carotid Sinus Syndrome
Subclavial Steal

VOLUME:
-Orthostatic Hypotension (9%)

NEUROLOGIC:
-TIA
-sublclavian steal
-Hypoxia

MEDICATION:
-CCBs
-BBs
-Digoxin
-Insulin
-QT Prolonging Drugs
-Drugs of Abuse

Question 3

DDX: ECG 2 basic things and 6 exotic things

Answer 3

Basic Things:
Arrythmia
Ischemia

Exotic Things:
Arrythmogenic Right Ventricular Dysplasia (epsilon waves, flipped t waves V1-V3)

Brugada (RBBB, STE, V1-V3)

Left Ventricular Hypertrophy (marked high voltage)

Pulmonary Embolism (Right axis shift, S1Q3T3, RBBB, Deep flipped t waves V1-V3)

QT too long / too short (Qt > 1/2 RR)

Wolf-Parkinson White

Question 4

History & Physical

Answer 4

Events preceding the loss of consciousness:
patient position
environmental stimuli
strenous activity
arm exercise
aura, prodrome / no prodrome

Duration of LOC

Tonic Clonic Activity
Foaming at mouth
Tongue trauma
Post ictal state

Chest pain, dyspnea on exertion, palpitations

Recent Illnesses / vomiting / diarrhea
Alcohol Ingestion
Dieting / weight loss

Witnesses

Question 5

Investigations

Answer 5

Electrolytes
Extended Electrolytes
Glucose
Creatinine
CBC
ECG: check PR, QRS, QT
BHCG
+/- CT Head if Neurological Findings

Question 6

Management: Stable

Answer 6

POC Glucose
Cardiology Consult
Echocardiography
Holter Monitor

Question 7

Disposition: Decision making rule

Answer 7

Canadian Syncope Rules

Question 8

Disposition: Low-Risk (No cardiac risk factors), clear vasovagal mechanism, normal ECG

Answer 8

Immediate discharge with no labs

Question 9

Disposition: Low-risk (no cardiac risk factors), no clear cause, normal ECG

Answer 9

After ED evaluation, observation with or without labs, no outpatient evaluation.

Question 10

Disposition: Intermediate-risk (advanced age with vagal mechanism or young age with some cardiac risk and no clear cause), normal ECG

Answer 10

After ED evaluation, observation with or without labs, outpatient evaluation with ambulatory monitoring