Syncope (Assessment and Plan): Difference between revisions
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Patient presents after (witnessed/unwitnessed) episode concerning for syncope. There was loss of consciousness. After the event the patient took XX minutes to recover. There XXX headstrike. The patient reports a prodrome consisting of XX (nausea, diaphoresis, lightheadedness, blurry vision). The patient XX chest pain, palpitations, SOB, numbness, visual changes. Patient also denies incontinence, tongue biting. If no loss of consciousness, but positive prodrome then patient had presyncope. The etiologies of syncope include unknown (36%), neurocardiogenic (21%), orthostasis (9%), cardiogenic (10%), stroke/TIA (4%), seizure (5%), and other miscellaneous (micturition, cough, situational; [https://www.nejm.org/doi/pdf/10.1056/NEJMoa012407 NEJM 2002]). | Patient presents after (witnessed/unwitnessed) episode concerning for syncope. There was loss of consciousness. After the event the patient took XX minutes to recover. There XXX headstrike. The patient reports a prodrome consisting of XX (nausea, diaphoresis, lightheadedness, blurry vision). The patient XX chest pain, palpitations, SOB, numbness, visual changes. Patient also denies incontinence, tongue biting. If no loss of consciousness, but positive prodrome then patient had presyncope. The etiologies of syncope include unknown (36%), neurocardiogenic (21%), orthostasis (9%), cardiogenic (10%), stroke/TIA (4%), seizure (5%), and other miscellaneous (micturition, cough, situational; [https://www.nejm.org/doi/pdf/10.1056/NEJMoa012407 NEJM 2002]). | ||
San Francisco Syncope Rule to Predict Serious Outcomes | San Francisco Syncope Rule to Predict Serious Outcomes (<nowiki>http://www.mdcalc.com/san-francisco-syncope-rule-to-predict-serious-outcomes/</nowiki>) | ||
- All cases: telemetry, orthostatic vital signs, CBC, head CT if concern for head strike | |||
- Suspect cardiac (mechanical): D-dimer / CT-PE if hypoxic (PE in 17% hosp pt with syncope [https://www.nejm.org/doi/full/10.1056/NEJMoa1602172 NEJM 2017]), trop, TEE, TTE only if murmur or known structural disease (<1% abnl w/o hx heart dz) ; (electrical) Discharge with rhythm monitor | |||
- | - Suspect neurocardiogenic: Reassurance + avoidance of provocative stimuli, educate patient on isometric counterpressure maneuvers (eg leg cross, hand grip). Several negative trials for Rx intervention (Fludrocort ([https://www.ncbi.nlm.nih.gov/pubmed/16781217 POST-II]), metoprolol ([https://www.ncbi.nlm.nih.gov/pubmed/16505178 POST]), PPM ([https://www.ncbi.nlm.nih.gov/pubmed/12734133 VPS-II]), tilt test no longer recommended. | ||
- | - Suspect orthostatic: re-evaluate beta-blockers, diuretics, antihypertensives, consider midodrine [5-10mg] if history highly consistent with orthostatic hypotension (or repeated episodes). | ||
- Suspect neurologic/seizure: Complete neuro exam, EEG | |||
- Suspect | |||
Revision as of 02:31, 11 August 2018
#Syncope
Patient presents after (witnessed/unwitnessed) episode concerning for syncope. There was loss of consciousness. After the event the patient took XX minutes to recover. There XXX headstrike. The patient reports a prodrome consisting of XX (nausea, diaphoresis, lightheadedness, blurry vision). The patient XX chest pain, palpitations, SOB, numbness, visual changes. Patient also denies incontinence, tongue biting. If no loss of consciousness, but positive prodrome then patient had presyncope. The etiologies of syncope include unknown (36%), neurocardiogenic (21%), orthostasis (9%), cardiogenic (10%), stroke/TIA (4%), seizure (5%), and other miscellaneous (micturition, cough, situational; NEJM 2002).
San Francisco Syncope Rule to Predict Serious Outcomes (http://www.mdcalc.com/san-francisco-syncope-rule-to-predict-serious-outcomes/)
- All cases: telemetry, orthostatic vital signs, CBC, head CT if concern for head strike
- Suspect cardiac (mechanical): D-dimer / CT-PE if hypoxic (PE in 17% hosp pt with syncope NEJM 2017), trop, TEE, TTE only if murmur or known structural disease (<1% abnl w/o hx heart dz) ; (electrical) Discharge with rhythm monitor
- Suspect neurocardiogenic: Reassurance + avoidance of provocative stimuli, educate patient on isometric counterpressure maneuvers (eg leg cross, hand grip). Several negative trials for Rx intervention (Fludrocort (POST-II), metoprolol (POST), PPM (VPS-II), tilt test no longer recommended.
- Suspect orthostatic: re-evaluate beta-blockers, diuretics, antihypertensives, consider midodrine [5-10mg] if history highly consistent with orthostatic hypotension (or repeated episodes).
- Suspect neurologic/seizure: Complete neuro exam, EEG