Syncope Assessment and Management

1. Assessment of
Syncope
Registrar Teaching
Emergency Department
Sir Charles Gairdner Hospital
01.08.2013
Mohamed Gaber
Registrar in Emergency Medicine
16.06.2010
M & M Meeting

2. Talk outline
Case Presentations with ECGs.
Any question in Italics is for open audience discussion.
Some discussion syncope decision rules and interesting ECGs.
Feel free to interrupt with remarks and questions.

3. Case Presentations

4. Case Presentation A
64 year old man presents to ED, brought in by wife at 20:00.
Was dusting shelf before dinner time, fell back onto couch.
Wife says was clammy and sweaty, patient remembers passing out.
Prior to passing out, he felt palpitations.
Nil chest pain, shortness of breath, bowel/bladder control issues.
Currently looks well and would like to go home.
PMHx – NSTEMI --- on Aspirin, β-blocker and statin.
Vitals – pulse 82, BP 142/87, RR 14, SpO2 98% RA, Temp 37.4, BSL 6.2.
Unremarkable chest, abdominal, neurological exam.
No postural drop, UA negative, CXR normal.
Bloods including Troponin normal.
Would you send this patient home?

5. Case A ECG

6. Case Presentation B
36 year old lady presents to ED from her place of work at 07:20 AM.
Was at the gym earlier in the morning, then rushed to work.
Feeling lightheaded and flushed on bus during journey to work.
Increased BMI noted, has been trying to lose weight.
Started exercising recently as GP confirmed hypercholesterol on bloods.
Nil other cardiac risk factors, nil contraception.
PMHx – hypercholesterol, nil medications.
Vitals – pulse 94, BP 110/73, RR 16, SpO2 98% RA, Temp 36.2, BSL 5.8.
Unremarkable chest, abdominal, neurological exam, large BMI noted.
No postural drop, UA negative, CXR normal.
Bloods including Troponin normal.
Would you send this patient home?

7. Case B ECG

8. Discussion

9. Differential is wide

10. Don’t forget drugs

11. Work up algorithms

12. San Francisco Syncope Rule (SFSR)

13. SFSR

14. Validation of the SFSR

15. NNT of the SFSR

16. Oh no

17. OESIL
Epidemiological Observatory on Syncope in Lazio
No prodromal symptoms
Age > 65
History of cardiac disease
Abnormal ECG

18. ROSE
Risk Stratification of Syncope in the ED

19. BNP... really?

20. Lets put them all together

21. This is beautiful

22. Further reading

23. Thank you
and
Questions