approach to Syncope patient in ED

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1. Syncope Al Yaqdhan Al Atbi , MD EM Resident

2. Outline Introduction Importance Pathophysiology Etiology and DDx Approach to a patient presented with syncope Disposition

3. Introduction Syncope or Fainting: a transient loss of consciousness, associated with loss of postural tone, with spontaneous return to baseline neurologic function requiring no resuscitative efforts . Near-syncope : a premonition of fainting without loss of consciousness

4. Definition

5. Why it is Important accounts for 0.8% of ED visits prevalence in the general population is 19 %. Most causes of syncope are benign and have favorable outcomes . Recurrence of syncope may be as high as 50% and is not correlated with age or sex . The clinical examination (history and physical examination) alone can suggest the diagnosis in 45% of cases The overall U.S. medical cost of syncope is estimated at $2.4 billion annually

6. Pathophysiology

7. Etiologies Common causes according to Framingham Heart Study: Vasovagal (reflex mediated, 21 %) cardiac (10 %) orthostatic (9 %) Medication related (7 %) Neurologic (4 %) unknown (37%). After ED investigation, the unknown proportion may be 50% to 60%.

8. VASOVAGAL AND NEURALLY/REFLEX-MEDIATED SYNCOPE : In appropriate vagal and sympathetic tone associated with inappropriate vasodilatation, bradycardia, or both lightheadedness , with or without nausea, pallor, and/or sweating , and an associated feeling of warmth A slow, progressive onset with associated prodrome suggests vasovagal syncope.

9. Exposure to certaine trigger may cause it.. Example: unpleasant sight, sound, or smell Fear severe pain emotional distress instrumentation Situational syncope occurs during or immediately after coughing, micturition, defecation, or swallowing.

10. PSYCHIATRIC DISORDERS Organic causes should be rolled out first 40 % vasovagal syncope & 62 % unknown Most common Dx : generalized anxiety disorder and major depressive disorder Young> elderly

11. NEUROLOGIC SYNCOPE Rare Patients with loss of consciousness with persistent neurologic deficits or altered mental status do not have true syncope. Subclavian steal syndrome Seizure

12. History Age Syncopal attack: Witnesses/unwitnessed Onset , duration , recovary Prior to attack Attack postsyncopal events Associated symptoms Past medical hx Medication HX

13. Carotid Massage: Carotid sinus Syndrome Hyperventilation Maneuver psychiatric (anxiety-provoking)

14. Disposition Inpatient: If life threaten condition detected Farther workup for high risk patient Out patient: Low risk patients

15. Take Home Message Syncope is a common presentation in ED. It can indicate for a life threaten conditions. The ED evaluation of syncope is often inconclusive

16. References Tintinalli’s Rosen