Syncope and Sepsis

Question 1

Describe the PE of syncope

Answer 1

1. Vital signs
   - Orthostatics: lay down for 3 min then sit up for 3 min then stand
2. Neck: carotid bruits, JVD
3. Lungs: rales, crackles (CHF)
4. Cardiac: new murmurs, irregular heart beat, ectopy, pauses
5. Abdomen: listen, palpate for AAA,
6. Extremities: edema, pulses, perfusion, cap. refill
7. Neurologic:

Question 2

Causes of neurocardiogenic syncope

Answer 2

24%

1. Vasovagal syncope
2. Situational (coughing postmicturation, defecation)
3. Carotid sinus

Question 3

Causes of cardiac syncope

Answer 3

18%

1. structural (HCOM)
2. Arrhythmia (long QT, Brugada, 3rd degree block)
3. vascular (subclavian steal)

Question 4

Causes of syncope

Answer 4

1. Neurocardiogenic 24%
2. Cardiac 18%
3. Orthostatic 8%
4. Meds 3%
5. unknown 34%
6. neurologic 10%

Question 5

Describe the PASSOUT causes of syncope

Answer 5

1. Pressure- vasovagal, orthostatic
2. Arrhythmia (get EKG)
3. Seizure (look for tongue or cheek biting)
4. Sugar
5. Output- severe AS or MS, MI, dissection
6. Unusual anxiety, panic attack, hyperventilation
7. Transient- migraines, head bleeds, TIA

Question 6

Vasovagal syncope is never associated with ___ and most commonly has __

Answer 6

exertion

precipitant-standing

**Vasovagal (MC idiopathic)

Question 7

Orthostatic syncope is most commonly in who

Answer 7

MC cause in elderly

Question 8

Causes of orthostatic syncope

Answer 8

1. Medications
2. Volume loss (GI bleed, dissection)
3. Situational

Question 9

Describe the initial syncope workup

Answer 9

1. HX
2. PE
3. EKG
   50% of cases of syncope can be diagnosed with the above. Also consider…
4. Labs: CBC, CMP, Glucose, Troponins
5. Imaging: Fast, CXR, Head CT if you suspect head trauma
6. Guaiac stool

Question 10

Other tests you can consider in the syncope workup include

Answer 10

1. Carotid US (in patient)
2. Holter monitor (OP)
3. Tilt table test (OP)

Question 11

Describe the Dispo of syncope

Answer 11

1. Cause directed.
2. “Low risk patients with single episode of syncope can be reassured without further investigation.”
   - F/U with PCP
3. Routinely consider admission to the hospital if elderly, hx cardiac disease (including EKG changes or PPM), new anemia, abnormal PE findings.
4. Use MDCalc–> syncope–> San Francisco Syncope Rule

Question 12

A clinical syndrome that has physiologic, biologic, and biochemical abnormalities caused by a dysregulated inflammatory response to infection.

Answer 12

Sepsis

Question 13

Sepsis is more common when

Answer 13

1. in AA males
2. in Winter months
3. older pts >65y/o
4. Increasing rates of sepsis multifactorial. (older populations, Abx over use, immunosuppressed ppl)

Question 14

Describe the MC pathogens that cause sepsis

Answer 14

Gram + bacteria (MC in US)

Gram – bacteria (MC w/ GI causes)

Fungal organisms

50% unidentified–> culture neg. sepsis

Question 15

Describe the continuum of sepsis

Answer 15

1. Infection
2. bacteremia
3. Sepsis
4. Septic shock
5. multiple organ dysfunction Syndrome (MODS)
6. Death

Question 16

Describe qSOFA

Answer 16

*Early sepsis identification for pts OUTSIDE the ICU

RR>22bpm
sBP<100mmHg
Altered GCS

0=Mortality <1%
1= Mortality 2-3%
>/=2 = Mortality >/= 10%

Question 17

Organ dysfunction: “defined as an increase in ___ points in the SOFA score.”

Answer 17

two or more

Question 18

Sepsis Risk Factors

Answer 18

1. Age 65 or older
2. ICU admission –> 50% get hospital acquired infection
3. bacteremia
4. Immunosuppression/asplenic
5. Diabetes
6. CAP
7. Prior hospitalization–> Altered microbioms
8. Genetics

Question 19

Describe the sepsis clinical presentation

Answer 19

1. Hypotension
2. Tachycardia
3. Fever >38.3 or <36C
4. Leukocytosis (not always)
5. Generally nonspecific
6. Cool, clammy skin
7. poor perfusion

Question 20

Describe the sepsis work up

Answer 20

Labs:

1. CBC
2. CMP
3. Lactate–> sign of hypoperfusion (>4 can indicate septic shock)

Consider:

4. ABG (risk of resp. failure)
5. coags (liver dysfunction/hypoperfusion)
6. Procalcitonin
7. Blood cultures

Imaging: as necessary
CXR if pulm. source
CT if suspect GI source

Question 21

How is the sepsis diagnosis made

Answer 21

• Diagnosis often made empirically.

- Constellation of signs / symptoms, lab findings indicative of sepsis.

Question 22

Describe the Tx of sepsis

Answer 22

1. 2 large bore IVs
2. Cardiac monitor with Q 15 min VS
3. Fluid resuscitation
4. Acetaminophen for fever
5. Early antibiotics (specific for each hospital)
   * Don’t delay Abx for cultures
6. Admit to the appropriate medical unit.

Question 23

What are factors that can affect the sepsis prognosis

Answer 23

1. Site of infection- UTI better prognosis than unknown, GI or pulmonary.
2. type of infection- Nosocomial has worse prognosis than community acquired.
3. Host related

Question 24

What septic infections have the worse outcomes

Answer 24

1. MRSA,
2. MSSA,
3. pseudomonas,
4. polymicrobial,
5. candida and
6. non-candida fungal infections have worse outcomes.

Question 25

What are host related factors that can affect sepsis prognosis

Answer 25

1. Failure to develop a fever.
2. Leukopenia
3. Thrombocytopenia.
4. Coagulopathy.
5. Hyperglycemia
6. Age
7. Comorbidities
8. New onset Afib

Question 26

Sepsis has better outcomes if…

Answer 26

1. Initiate appropriate antibiotics early.
2. Restore perfusion
3. Early and aggressive resuscitation
4. Normalization of lactate.