Assessing Syncope and
Loss of Consciousness
SYNCOPE
•
70 yr old male presents following syncopal
episode while shopping. He has had 2
previous syncopal episodes that have not
been investigated.
•
He currently feels a little unwell.
•
At triage BP 120/80, PR 83.
•
Should this man be admitted?
•
SYNCOPE
•
Brief loss of consciousness associated
with inability to maintain postural tone that
spontaneously and completely resolves
without medical intervention
•
PRE SYNCOPE
•
A warning of syncope that does not result
in LOC
•
Syncope accounts for 1-3% ED visits and
6% admissions.
•
In ED need to determine cause and if one
cannot be found which pts are at greatest
risk of serious outcome ie. risk
stratification.
CAUSES OF SYNCOPE
CARDIAC
• Arrythmias
• Ischaemia
•Obstructive lesions
-HOCM
-Aortic Stenosis
-Mitral Stenosis
NEUROLOGICAL
•Seizure (usually easily differentiated)
•TIA ( VBI)
•SAH
PULMONARY - PE
PERIPHERAL VASCULAR
• vasovagal
- warning signs
- quick recovery
- <40 yrs 1st time
• orthostatic
- intravascular volume depletion or autonomic
dysfunction
- blood loss /dehydration
- drug induced
- diabetes
MISCELLANEOUS
•Hypoglycaemia
•Hyperventilation
•Anaphylaxis
PSYCHIATRIC
•conversion disorders (50% young pts)
•personality disorders
•
HISTORY
•
previous syncope
•
known -IHD,CCF, arrhythmias
•
medications
•
blood loss
•
circumstances of syncope
•
- prodrome
•
- position
•
- exertional
•
- associated symptoms
•
Family history
•
EXAMINATION
•
Full exam but most importantly
•
BP (lying, standing)
•
pulse
•
PR
•
Injury assessment
•
INVESTIGATIONS
•
BSL
•
ECG
•
FBC
•
UEC
SYNCOPE WITHOUT OBVIOUS CAUSE
San Francisco Syncope Rule (2002)
• Identifies those pts at risk of serious
outcome (death, AMI, arrhythmia, PE, stroke,
SAH, haemhorrage, return visit to ED.)
- systolic BP <90 in ED
- Abnormal ECG
- Hct <30
- SOB
- history of CCF
• If pt has none of above there is no risk of serious
outcome related to the syncopal episode (100%
sensitive, 49% specific)
• Numerous studies since to validate (less
sensitivity /specificity)
OESIL (2002)
•Predictors of mortality within 12 monthscumulative score:
- age >65 yrs
- cardiovascular disease in history
- syncope without prodrome
- abnormal ECG
•0% score 0, 0.8% score 1, 19.6% score 2,
34.7 % score 3, 57.1% score 4
ROSE (British)
•Elevated BNP, Haemoccult +ve, anaemia, low O2
sats,presence Q waves on ECG predict serious
outcome at 30 days.
87% sens, 98% neg pred value.
Many studies but no highly sensitive reliable tool is
yet available. Cardiac disease is recurring theme –
cardiac syncope kills.
ACEP level A recommendation for investigation of
syncope – history and ECG.
•
So should we admit this man ?
•
How long do we keep him for ?
•
What tests and monitoring does he
receive?
PROLONGED ALTERED STATE OF
CONSCIOUSNESS
• By definition NOT syncope
• Glasgow Coma scale is a universal tool used to
assess and document individual patients progress
in globally understood terms.
Prolonged altered states of consciousness with
GCS <12/13 will be due to either a neurological
cause, a systemic cause that leads to hypoperfusion
of the brain or a toxic, infective or metabolic problem
that may be affecting the whole body (but presenting
as a neurological emergency).
•
Different causes to those of syncope:
Neurological
• vascular
• neoplastic
• oedema
• infective
• trauma
• status epilepticus
Infective
• generalised sepsis
Metabolic
• hypo/hyperglycaemia
• uraemia
• hyper/hypocalcaemia
• liver disease
Toxins
• alcohol et al
Respiratory
• hypoxia/ hypercarbia
Biochemical
• eg. Hyponatraemia
Hypo/hyperthermia
Endocrine
• hypothyroid
• Approach to patient with altered LOC should
always be the same.
•ABC