Syncope (Assessment and Plan)

#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