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SYNCOPE a symptom, not a diagnosis… Clinical cases

SYNCOPE a symptom, not a diagnosis… Clinical cases. Dr Jaycen Cruickshank Ballarat Emergency Education. Learning objectives they need to be your objectives…. To apply your knowledge and the information presented in our syncope presentation to these cases

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SYNCOPE a symptom, not a diagnosis… Clinical cases

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  1. SYNCOPEa symptom, not a diagnosis… Clinical cases Dr Jaycen Cruickshank Ballarat Emergency Education

  2. Learning objectivesthey need to be your objectives… • To apply your knowledge and the information presented in our syncope presentation to these cases • To make a diagnosis and safe management plan for each case • For ACEM trainees • To consider how these cases might appear and be answered in the FACEM exams • To write and complete practice questions • To realize that good answers in exams are often good answers when in charge of the ED.

  3. Case 1 • 32 yo male, Intravenous drug user • Presents with frequent syncopal episodes and ? Seizure activity • Medication – methadone • PMHx – nil else significant

  4. Case 1 ECG

  5. Case 1 ECGWhat would you do if this then happened?

  6. Reminder causes ofQT prolongation • Hypomagnesiuaemia • Hypokalamia • Hypocalcaemia • Na Channel blockers – type 1a, TCA • Raised ICP • Altered conscious state • Hereditary • Lange Nielsen – QT prolongation and deafness • Romano Ward - QT only • Hypothermia • Drugs

  7. Clinical Case 2 • 19 year old university student • Wakes up Sunday morning to the sound of his mobile phone • Gets up out of bed, talks for half a minute, then feels funny and blacks out • Housemate hears phone and the fall, and runs into the room, he is coming around quickly • Referred by GP for ED assessment • ECG normal • Further assessment and management?

  8. Case 3middle aged man with fainting episode • ED doctor presents to the ED physician… • Middle aged man with syncope • No features to suggest seizure • Full assessment and no obvious cause • Is there any role for a troponin now and eight hours, how long should we observe for?

  9. Case 3 cont. • History of presenting complaint. • He drove 8 hours • Walked into house • Went to make cup of tea • Then syncopal episode • Rapid recovery to normal… he heard wife calling the ambulance • Background • Truck driver • Working 2 jobs • Very little sleep • Past history similar episode • Investigation EEG and echo and stress test normal

  10. Case 39 year old • 39 yo syncopal episode • No prodrome • No pmhx • Normal physical examination • Ddx?

  11. ECG

  12. ECG brugada

  13. BRUGADA SYNDROMEPOLYMORPHIC VT1/3 will develop 2nd episode in 2 years

  14. Case 416 year old • 16 year old with syncope whilst playing basketball at school • No prodromal symptoms • Awoke after a few seconds • No PMHx • No FHx

  15. 16 year old, syncope while playing basketballInterpret this ECG.

  16. HYPERTROPHIC OBSTRUCTIVE CARDIOMYOPATHYWALL THICKNESS PREDICTOR OF DEATHSUBGROUP WILL NEED AN ICD

  17. Clinical case 5 • 25 year old with syncope during a lecture • No chest pain, no dyspnea • No PMHx • FHx – father died suddenly aged 60

  18. Further history • Further history • Syncope while seated • May indicate arrhythmia • Need more details on what lecture was about, the family history • Needs ECG • AA Arrhythmia, brugada, CMP

  19. Case 5 cont. What is your diagnosis?

  20. Case 5 cont. WPW

  21. Clinical case 6 • 68 yo presents following syncopal event following going to the bathroom at 4am • Situational • Micturition/defecation syncope • What if fainted before going to toilet? • How does that change things?

  22. Clinical Case 6 • 45 year old man collapses and takes 6 or 7 minutes to wake up and then he is a little confused • Diagnosis? • Probably a seizure • What further history and examination would be relevant?

  23. Clinical case 7courtesy emcore.com • A 52 year old man is brought to the ED following a collapse. • He had been sitting at the kitchen table reading the paper and the next thing he knew he was on the floor • He woke with a vice like headache and pins and needles down the left arm • He is in AF

  24. Clinical Case 7 further history • The patient had a biopsy of his ear where there was carcinoma detected • He had just got home following a CT of his neck, looking for lymph node enlargement • He had the CT with him and had asked people to look at the report, but no one would tell him what it meant • His brother died three months earlier from cancer

  25. Clinical case 7 • He was sitting at the kitchen table thinking about dying from cancer and getting very anxious. • He got hot and sweaty, felt a little dizzy and collapsed • When he awoke, he did have a vice like headache and pins and needles down left arm. He was in AF • He was seeing his cardiologist for AF, which was controlled and he was on aspirin • Two previous episodes • Previously investigated CT/LP normal, diagnosis migraines was made.

  26. Summary • History, exam, ECG • Cardiac vs non cardiac • Admit for no diagnosis and high risk • Older/abnormal ECG, cardiac history including CCF • Don’t forget to look for other causes • E.g TIA, dissection.

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