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Collapse ? cause. Why is this an important topic to master?. One of the great skills in EM is the ability to risk stratify patients accurately and t o formulate an informed management plans.

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why is this an important topic to master
Why is this an important topic to master?
  • One of the great skills in EM is the ability to risk stratify patients accurately andto formulate an informed management plans.
  • It is also important to enable the patient to make an informed decision in understanding proposed investigations, their risks and benefits and consenting to further investigation.
a case
A case
  • So lets think of a case to start with
  • 60 years man
  • Comes in following a collapse at the shops, an ambulance is called and the paramedics bring him to your ED. On arrival he’s alert and orientated
  • GCS 15
  • Pulse 80 bpm
  • BP 120/80
  • RR 16
  • SpO2 on air 99%
  • Temp 36.2
  • BM 5.7
  • He’s been well for the past few days, no history pointing you towards a diagnosis, no significant PMH. No meds and his examination is completely unremarkable,
the paper
the paper
  • By Quinn J et al.
  • Annals of Emergency Medicine 2006
  • ‘Prospective validation of the San Francisco Syncope Rule to predict patients with serious outcomes’
about the sanfrancisco suncope rule
About the SanfranciscoSuncope Rule
  • The rule that they’re attempting to validate is the ruel they produced to risk stratify patients into low and high risk of morbidity and mortality. It is also referred to as the CHESS score, which stands for…..
  • C – ongetsive cardiac failure
  • H – ct < 30%
  • E – CG abnormality – any
  • S – ystolic BP < 90 mmHg
  • S – hortness of breath in the history
inclusion criteria
Inclusion criteria
  • Patients with a symptom of syncope
  • Syncope was defined as a ‘transient loss of consciousness with return to baseline neurological function
  • Prospective study between 2002-2004
exclusion criteria
Exclusion criteria
  • Trauma-associated LOC
  • Alcohol/drug involvement
  • Definite seizure
outcome measures
Outcome measures
  • 30 follow up after the index visit to the ED and determined short term outcomes that would mandate emergency admission
  • Short term serious outcomes
    • Death
    • MI
    • Arrhythmia
    • PE
    • Stroke
    • SAH
    • Significant haemorrhage/anaemia requiring transfusion
    • Any condition causing/likley to cause a return visit
    • Procedural intervention to treat a related cause of syncope
acute interventions defined as
Acute interventions defined as…..
  • A procedure required to treat a condition related to the patient’s syncope
    • Dialysis
    • Pacemaker insertion
    • Surgery for valvular heart disease
    • Baloon pump insertion
    • Vasopressor use
    • Surgery for an AAA/ruptured spleen/ectopic pregnancy
    • Endoscopy for varices
results
Results
  • Information gathered for 767 visits
  • Average age of 61 years, 13.7 % of patients were deemed to have had a serious outcome
  • San Francisco rule classified 52% of patients as high risk
  • If the rule had been used to determine admission/discharge decisions it would have decreased admissions by 7%
  • The study was powered to determine sensitivity and specificity with 95 % Cis within 10% (which it just failed to achieve with the sensitivity).
  • The rule was 90% sensitive (95 % CI 89-100%) and 56 % specific (95% CI 52-60%) in predicting serious outcomes
references
References
  • Quinn J, McDermott D, Stiell I, Kohn M, Wells G. Prospective validation of the San Francisco Syncope Rule to predict patients with serious outcomes. Ann Emerg Med. 2006;47(5):448-54.