Management of Syncope in the Emergency Department: Insights & Case Studies

1. Management of Syncope in the Emergency Department Jonathon M. Sullivan MD, PhD Honorary Professor Syncopatus Emeritus BullshitticusMaximusDuplicitus Department of Emergency Medicine Wayne State University DFO’s for dummies

2. LIMITS AND BOUNDARIES • Won’t talk about pediatric syncope • What are these “children” things I keep hearing about? • Won’t parade a bunch of papers • You’re welcome • This isn’t an EKG conference • Leave it to the Berkserker • Outpatient workup of syncope • About 50% Voodoo anyway

3. CASE STUDY: • 48 yo maladjusted WM EP w. no PMH has witnessed LOC while standing at pt bedside (work hour 13), sustaining head injury. • Brief prodrome of fatigue, stress, dizziness, sandwich-related thoughts. • Overcaffeinated, up for 16.5 hours, minimal food or H2O due to workload. • No pulse palpated for about 5s, CPR briefly initiated. • Return of consciousness at 10-20 secs: • Slightly confused but appropriate: • “Get the f**k up off me.” • Exam shows a poorly-groomed middle-aged hump with normal VS, congenital anisocoria (no burr holes, please), small occipital scalp lac, CTA, RRR, normal neuro, pulse ox 99%.

4. QUESTIONS: • What are the immediate treatment/stabilization priorities? • Is this syncope or something else? • Is the differential for syncope • Quite Extensive, • Humongoid, or • Galactically colossal? • What are the relevant historical and physical exam findings? • What tests, if any, would you order on this doofus? • What is the best way to make this guy somebody else’s problem?

5. IMMEDIATE PRIORITIES: • This is 2009: • Check insurance status • Register patient • Print stickers • Click 29-minute box • Use foam on entering module • Handwashing Gestapo are everywhere • Approach the customer with a bright DMC smile. • ABCs, monitor, O2, IV • C-spine precautions • Check glucose?

6. WAS THIS SYNCOPE? • If so, why? If not, why not?

7. WHAT IS SYNCOPE? • συγκοπή– “syncopa” to cut off. • Cut off what? • Greek guys didn’t say. • Syncope = transient loss of consciousness and postural tone with rapid onset and spontaneous, prompt and complete recovery without intervention. • So: Did our patient have syncope?

8. WHAT COULD CAUSE SYNCOPE? • Anything that causes a sudden, transient loss of consciousness can cause syncope. • Assumes that we know what consciousness is. • Consciousness can report only its presence, not its absence. • But that’s another lecture. • In most people, the organ of consciousness is the brain. • Therefore, syncope is a manifestation of brain (end-organ) dysfunction. • At the neurological level, only two things can cause syncope: • Transient brainstem dysfunction at the level of the RAS; or • Transient bilateral cerebral dysfunction. • This is a tall order! What could do this?

9. WHAT COULD CAUSE SYNCOPE? • NEUROGENIC:

10. WHAT COULD CAUSE SYNCOPE? • TOXIC-METABOLIC • ALCOHOL • SEDATIVE-HYPNOTICS (HERON, ETC) • SYMPATHOMIMETICS (CAINE, CRANK, ETC) • AXE BODY SPRAY AND OTHER WHIFFERS • GLUCOSE • SODIUM • CALCIUM • POTASSIUM • HISTAMINE, ALLERGIC REACTIONS • HYPOXIA

11. WHAT COULD CAUSE SYNCOPE? • CARDIOVASCULAR • The critical organ system… • …that constantly pumps… • …the essential good stuff… • …that makes the brains go. • SUTTON’S LAW: • “That’s where the money is.”

12. WHAT COULD CAUSE SYNCOPE? • CARDIOVASCULAR: • Arrhythmias • Bradycardias • Carotic sinus sensitivity • Sick sinus syndrome • Heart blocks • Pacemaker malfunction • Tachycardias • Malignant • “stable” • Think long QT, Torsades, SVT, VTach • Obstruction to flow • Left-sided: Hypertrophic cardiomyopathy, left atrialmyxoma, aortic stenosis, mitrialstenosis • Right-sided: PE, pulmhtn, pulmonicstenosis, right atrial myxoma • Valvulopathy • PE • Vascular Catastrophes • Dissection • Ruptured AAA • Vasomotor • Orthostasis and hypovolemia • Autonomic dysfunction • Situational syncope • Anaphylaxis—bee stings, scromboid, drug rxs, etc. • “Vasovagal syncope”

13. WHAT COULD CAUSE SYNCOPE? • VASOVAGAL • One of the most notorious wastebasket diagnoses in clinical medicine. • Derives from ignoramus • An ancient Greek work meaning “doctor has no f**k’n clue why you dfo’d.” • More general (and therefore, usually, more correct) term is neurocardiogenic syncope. • Proximate cause is actually increased vasomotor tone and cardiac contractility

14. WHAT COULD CAUSE SYNCOPE? • VASOVAGAL • Can occur in any susceptible patient when precipitated by any event which causes: • Venous pooling • Increased sympathetic tone • May be both caused (pooling) or exacerbated (enhances reflex) by alcohol. • Patients are fine immediately after precipitant (such as standing), then dfo as reflex kicks in.

15. WHAT COULD CAUSE SYNCOPE? • VASOVAGAL BRADYCARDIA, VENODILATION, DFO INC SYMP’TIC TONE BETZOLD-JARISH REFLEX VENOUS POOLING ALL KINDSA STUFF!

16. WHAT COULD CAUSE SYNCOPE? • VASOVAGAL

17. WHAT COULD CAUSE SYNCOPE? • VASOVAGAL • High-Risk Diagnosis. Why? • Because this is what you’ll put on the chart when you send that guy home with the ruptured AAA. • Don’t make the diagnosis of “vasovagal” unless you have clear historical and exam findings to support it. • In fact, try not to make this diagnosis at all. There’s nothing wrong with a final impression of “syncope.” • “You don’t have to make the right diagnosis. You just have to make the right decision.” • El-Rod

18. WHAT COULD CAUSE SYNCOPE? • SITUATIONAL SYNCOPE

19. WHAT COULD CAUSE SYNCOPE? • SITUATIONAL SYNCOPE • Fear, pain, stress • Hunger • Unbearable sights • Blood, vomit, filth • Violence, death • Fat people in spandex • Elvis, Hitler, Brad Pitt • Urination, defecation, sneezing, coughing, swallowing • Decreased venous return/Valsava • BJ reflex?

20. WHAT COULD CAUSE SYNCOPE? • BY FREQUENCY (fr Henry et al): • COMMON: • VT, SVT • Hypovolemia: bleed-ING from AAA, ectopic, GIB, etc • Vasovagal • Situational: cough, micturition, defecation • Drug-induced – usually cardioactive agents

21. WHAT COULD CAUSE SYNCOPE? • BY FREQUENCY (fr Henry et al): • LESS COMMON: • PE • Heart block • Valvulopathy (stenosis) • MI • Pacemaker malfunction • SAH • Psychogenic • Bradycardias • Psychogenic

22. WHAT COULD CAUSE SYNCOPE? • BY FREQUENCY (fr Henry et al): • RARE (BUT IMPORTANT): • Aortic dissection • Basilar migraine/TIA • Trigeminal or glossopharyngeal neuralgia • Sublcavian steal • Pulmonary hypertension • Atrial myxoma

23. WHAT COULD CAUSE SYNCOPE? • SULLYDOG’S BOTTOM LINE: • Toxic-metabolic – not unheard-of, especially with cardio/vasoactive agents, but relatively uncommon • Neurogenic – extremely uncommon, especially in the absence of persistent neurologic symptoms or neuro findings • Cardiovascular – Sutton’s law applies.

24. WHAT HISTORICAL AND EXAM FEATURES ARE IMPORTANT? • ALL OF THEM. SERIOUSLY. • H&P is the key to risk stratification in syncope. • HISTORY-Use eyewitnesses if available • Duration of LOC • Possible precipitants, prodrome • Convulsions – not all that convulses is seizure • Trauma • Seated vs. standing • Disorientation after ROC • PMH, Medications, All, SHx, FHx • Focus on hx of cardiovasc disease (esp CHF), vasoactive meds, cns agents, diuretics, meds for ED, FHx of sudden death.

25. WHAT HISTORICAL AND EXAM FEATURES ARE IMPORTANT? • EXAM: • They don’t call ‘em “vital signs” for nuttin’. • Orthostatics—fuggedaboudit. • No agreement on numbers; nobody does them right, especially in ED. • Sens/Spec totally suck ass. • Just think about it: • Syncope is usually cardiovascular/vasomotor • Orthostasics, if properly done and if positive, suggest either hypovolemia (easily detected with history or other exam findings) or a cardiovascular/vasomotor cause. • So orthostatics help us make better decisions…how? • Thanks for playing. • Trauma-CHI, tongue biting, C-spine • Signs of CHF—big mortality correlation • Abdominal/rectal: Tenderness, occult blood, Big Red. • Neuro: absence of findings strongly argues against neurogenic syncope.

26. WHAT TESTS WOULD YOU ORDER ON THIS DOOFUS? • Accu-check? • Lytes, BUN, Cr/gluc, Ca, Mag, Phos, AST, ALT, Amylase, Lipase, TFTs, PT/PTT, UA, UDS, SDS, Lactate, Osms? Right? • CT of the Brains? • EKG? • Chest x-ray? • Orthostatics? • Other?

27. WHAT TESTS WOULD YOU ORDER ON THIS DOOFUS? • Number One Rule: Use your history and physical to guide testing. What a concept, huh?

28. WHAT TESTS WOULD YOU ORDER ON THIS DOOFUS? • EKG • Low yield, but • Highly specific when positive • Cheap, noninvasive, makes you look very doctor-y. • Arrhythmias, blocks, pre-excitation syndromes, long QT, Brugada, MI, LVH, etc. • Monitor • Oh, for crying out loud. Why wouldn’t you? • May detect badness not seen on 12-lead snapshot • 4 factors suggest benefit of extended monitoring • Old dudes, heart disease, nonsinus rhythm on EKG.

29. WHAT TESTS WOULD YOU ORDER ON THIS DOOFUS? • THE OBLIGATORY EKG SECTION

30. WHAT TESTS WOULD YOU ORDER ON THIS DOOFUS? • THE OBLIGATORY EKG SECTION

31. WHAT TESTS WOULD YOU ORDER ON THIS DOOFUS? • THE OBLIGATORY EKG SECTION

32. WHAT TESTS WOULD YOU ORDER ON THIS DOOFUS? • THE OBLIGATORY EKG SECTION

33. WHAT TESTS WOULD YOU ORDER ON THIS DOOFUS? • THE OBLIGATORY EKG SECTION

34. WHAT TESTS WOULD YOU ORDER ON THIS DOOFUS? • Rapid Glucose • Who gets syncope from hypoglycemia? • Nobody, that’s who. • Remember the definition of syncope: • Syncope = transient loss of consciousness and postural tone with rapid onset and spontaneous, prompt and complete recovery without intervention. • How many hypoglycemics present like this? • Test is cheap and safe, but diagnostic yield approaches zero. • Absolute indication: • Attending tells you to get it.

35. WHAT TESTS WOULD YOU ORDER ON THIS DOOFUS? • OTHER LABS • Yield is extremely low, unless used to confirm specific suspicions raised by exam. Routine use is not recommended anywhere in the current literature. Caveats: • All women are pregnant. • All pregnant women have ectopics. • Hct < 30% predicts adverse events. • Of course, so does syncope. • d-dimer in suspected PE w. syncope is loser-ness. If you suspect PE + syncope, image.

36. WHAT TESTS WOULD YOU ORDER ON THIS DOOFUS? • IMAGING

37. WHAT TESTS WOULD YOU ORDER ON THIS DOOFUS? • IMAGING • ACEP: “There is no evidence to suggest that routine screening of syncope patients with advanced imaging (such as CT), functional echo, or EP testing is indicated.” • No neuro findings on H&P + no CHI = no CT. • Echo indicated only in patients with cardiac disease, abnormal EKG, suspected aortic stenosis. • Consider rapid US to screen for AAA in selected patients.

38. HOW CAN WE MAKE THIS GUY SOMEBODY ELSE’S PROBLEM? • SEVERAL QUESTIONS OBTAIN: • Which patients with syncope will croak soon? • REALLY soon: admit • KINDA soon: close followup. • Or admit. Whatever keeps your undies dry. • Which patients with syncope need an outpatient workup, and what kind of workup is that? • Which patients with syncope, if any, need to just get on with their lives?

39. HOW CAN WE MAKE THIS GUY SOMEBODY ELSE’S PROBLEM? • THE NACHRUL HYSTERY OF SYNCOPE PROGNOSIS EXCELLENT NOT SO MUCH

40. HOW CAN WE MAKE THIS GUY SOMEBODY ELSE’S PROBLEM? • THE NACHRUL HYSTERY OF SYNCOPE • Actual data: • Pts with cardiovascular cause have “strikingly higher” incidence of sudden death • Pts with CHF have high mortality whether or not the CHF “caused” the syncope • Translation: CHF is bad. • Age > 65 = high mortality. (Ya think?) • Abnormal EKG is NFG.

41. HOW CAN WE MAKE THIS GUY SOMEBODY ELSE’S PROBLEM? • ACEP HIGH-RISK / ADMISSION FACTORS: • “Older age” and associated comorbidities • Hct < 30 • History or presence of CHF, CAD, or structural heart disease

42. HOW CAN WE MAKE THIS GUY SOMEBODY ELSE’S PROBLEM? • THE CHESS RULE(San Francisco Rule) • CHF – pre-existing or new finding • Hematocrit < 30% • ECG Abnormality • Shortness of breath • SBP < 90 mmHg on arrivall • Initial Validation Set promising • Followup studies: not so much • CHESS seems to be better at telling you who to bring in than who to send home

43. HOW CAN WE MAKE THIS GUY SOMEBODY ELSE’S PROBLEM? • OTHER “DECISION RULES” • Boston Syncope Rules • Remains to be validated • 25 frippin’ criteria! • Mnemonic:

44. HOW CAN WE MAKE THIS GUY SOMEBODY ELSE’S PROBLEM? • WHO CAN GO HOME? • Patients who don’t need to be admitted. • Young and otherwise healthy, no major comorbidities • No neuro findings • No cardiovascular history or findings, normal EKG • No evidence of bleedING, guaiacneg, Hct>30 (if checked) • Targeted studies (eg, CTPA, US for ectopic, LP for SAH) negative • Good followup • Sullydog

45. WHAT HAPPENED TO SYNCOPE GUY?

46. WHAT HAPPENED TO SYNCOPE GUY? • EKG negative • Head CT negative • Labs negative • Serial trops negative • Perfusion stress negative • Attitude negative • No additional episodes • 1-year outcome pending

47. IS OUR DOCTORS LEARNING? • LET’S REVIEW, SHALL WE? • Syncope is a sudden, transient, self-limited loss of awareness and postural tone caused by global (not focal) dysfunction of the consciousness organ. • In most of us, that’s the brain. • Neurogenic and metabolic causes are very rare. • Cardiovascular and vasomotor causes are very common. • Risk stratification and indications for admission and testing come almost exclusively from H&P. • Aside from Hct, routine lab tests are just about worthless.

48. IS OUR DOCTORS LEARNING? • LET’S REVIEW, SHALL WE? • Routine imaging is very low yield. Targeted imaging is useful. • Admission criteria: • Any Sick Old Geez with: • Heart Dis-eeZ • Goofy EKG-eeZ • Low BP-eeZ • Suckin’ Wind/Wh-eeZE, or • Low CBC-eeZ. • Now THAT’s a mnemonic.

49. IS OUR DOCTORS LEARNING? • LET’S REVIEW, SHALL WE? • The Sullydog Admission Rule: • Old + Syncope = Admit. • May not meet interqual admission criteria. • Ask me later what I think about interqual admission criteria. • Lie to get them admitted if you have to. • (Sullydog is a moral relativist.) • Insert Heated Argument Here.

50. IS OUR DOCTORS LEARNING? • LET’S REVIEW, SHALL WE? • Discharge Criteria: • Patient does not require admission.