“I passed out” Frederick Korley M.D., Department of Emergency Medicine
Top 5 causes of Syncope 1. Unknown 36.6% 2. Vasovagal 21.2% 3. Cardiac 9.5% 4. Orthostatic 9.4% 5. Medication 6.8% Study participants from the original Framingham Heart Study and in the Framingham Offspring Study who underwent routine clinical examinations between 1971 and 1998. 7814 patients followed 822 reported syncope. Soteriades ES, Evans JC, Larson MG, Chen MH, Chen L, Benjamin EJ, Levy D. Incidence and prognosis of syncope. N Engl J Med. 2002 Sep 19;347(12):878-85.
Framingham Heart Study “Persons with cardiac syncope are at increased risk for death from any cause and cardiovascular events, and persons with syncope of unknown cause are at increased risk for death from any cause. Vasovagal syncope appears to have a benign prognosis.” Soteriades ES, Evans JC, Larson MG, Chen MH, Chen L, Benjamin EJ, Levy D. Incidence and prognosis of syncope. N Engl J Med. 2002 Sep 19;347(12):878-85. Note: There is a very nice table in the article: PubMed
San Francisco Syncope Rule – Decision Tree CHESS Predictors of Short-Term Serious Outcomes Abnormal ECG Shortness of Breath Systolic Blood Pressure Hematocrit Congestive Heart Failure Very nice figure in Article: PubMed Quinn JV, Stiell IG, McDermott DA, Sellers KL, Kohn MA, Wells GA. Derivation of the San Francisco Syncope Rule to predict patients with short-term serious outcomes. Ann Emerg Med. 2004 Feb;43(2):224-32.
Don’t forget to….. • Confirm that patient is at baseline mental status • Examine c-spine for tenderness • Look for bruises, cuts, tongue laceration • Listen for new murmur • Rectal exam for those who may have GI bleed as the source of their syncope • Tetanus shot for those who need one • If female, make sure she is not pregnant • Make sure patient is able to walk before you think of sending them home
Disposition • Will you admit or you send the patient home?
ACEP Clinical Policy on Evaluation and Management of Syncope - 2001 • What data help to risk stratify patients with syncope? • Age > 60 + CAD = high risk • Age < 45, no CAD = low risk • Physical exam signs of CHF = high risk • Who should be admitted after a syncopal event? • History of CHF or ventricular arrhythmias • Associated chest pain or symptoms compatible with ACS • Signs of CHF or valve disease on exam • EKG with ischemia, arrhythmia, prolonged QT, BBB • Consider admission for: age > 60, h/o CAD, congenital heart disease, FHx of sudden unexpected death, exertional syncope in younger patient
Torsades de pointes • A form of polymorphic V. tach that occurs in the setting of prolonged QT interval, T wave abnormalities or increased U wave amplitude • Changing morphology of QRS complexes that seem to twist around an imaginary baseline • Corrected QT(QTc) > 440ms • Usually self terminating but can result in V. fib
Causes of long QT and Torsades de pointes There are significant causes of prolonged QT syndrome Congenital Acquired: Medications Electrolytes Cardiac disease Starvation …to name a few Nice Table in article:PubMed Gowda RM, Khan IA, Wilbur SL, Vasavada BC, Sacchi TJ. Torsade de pointes: the clinical considerations. Int J Cardiol. 2004 Jul;96(1):1-6.
Commonly used drugs that can prolong QT • Antiarrhythmics Mainly Class 1A, 1C and III eg: Procainamide, flecainide, Sotalol, Ibutilide, amiodarone • Antimicrobialse.g.: Macrolides, fluoroquinolones, azole antigungals, ampicillin, bactrim • Antihistaminese.g.: Benadryl, Hydroxyzine • Antidepressantse.g.: doxepin, fluoxetine, paroxetine, imipramine, clomipramine, citalopram • Antipsychoticse.g.: Haldol, droperidol, lithium, chloral hydrate, chlopromazine, prochloperazine • Othersfosphenytoin, hydrochlorothiazide, tamoxifen, antimigraine agents, furosemide, reglan, cisapride, cocaine Gowda RM, Khan IA, Wilbur SL, Vasavada BC, Sacchi TJ. Torsade de pointes: the clinical considerations. Int J Cardiol. 2004 Jul;96(1):1-6.
Risk factors for drug induced torsades de pointes Congenital long QT Female Gender Electrolyte abnormalities Diuretics Bradycardia Etc. etc. Gowda RM, Khan IA, Wilbur SL, Vasavada BC, Sacchi TJ. Torsade de pointes: the clinical considerations. Int J Cardiol. 2004 Jul;96(1):1-6. Nice Table in article:PubMed
Methadone induced Torsades de pointes • Can occur with increasing doses of methadone, polysubstance abuse, taking other drugs that also prolong QT, etc One Swiss paper reports 5 cases Sticherling C, Schaer BA, Ammann P, Maeder M, Osswald S. Methadone-induced Torsade de pointes tachycardias.Swiss Med Wkly. 2005 May 14;135(19-20):282-5.
Treatment of Torsades • IV, O2, Monitor, pacer pads • Stop offending drugs • Check electrolytes including mg • Give Magnesium 2g over 1-2 mins, may repeat in 15 mins if necessary • May use isoproterenol or atropine to increase HR and shorten QT (atropine may be easier to get in ED, ISO is contraindicated in ischemic heart and congential long QT) • May overdrive pace with ventricular rate >90 • Replete K if low