+ More history HPC: No CP, SOB, palpitations, headache immediate pre or post faint No recent illness, no hosp admissions for >10y PMH – HTN, hypothyroid (last check 3m ago), breast cancer 14y ago DH: amlodipine, bendroflumethazone, ramipril (started 4d ago), levothyroxine SH: lives with husband, both well, independent, stairs at home, family supportive
+ Examination Looks well Afeb, BP 120/76, HR 72, sats 99 RR 12 CVS N HS, JVP normal, minimal ankle pitting oedema RS Abdo Neuro grossly normal What else do you want?
+ Syncope: ED investigation Postural BP – 120/76 lying stand up then wait 2 mins, 91/70 BM – 6.1 FBC U&E TFT all normal ECG…
+ Vasovagal – secondary to: hunger, dehydration, intercurrent illness, stress, micturition and… Postural hypotension: Recognised complication of ACE-I (and all BP lowering meds) Increased likelihood with autonomic dysfunction of age Can also indicate acute bleed – think occult GI bleed (Hb, Ur)
+ Differential diagnosis Arrhythmia (brady or tachy) – not always persistent on ECG, look for clues (PR, QTc) Heart failure – CCF / HOCM ACS Neuro – seizure, SAH AAA / thoracic aortic dissection Hypoglycaemia Other metabolic causes (Na, Ca… which can contribute to an arrhythmia or a seizure)
+ American College of Physicians Guidelines Admit: Hx Coronary Artery Disease, CCF, VT Chest pain Signs of CCF, valve dis, stroke, focal neuro ECG ischaemia, arrhythmia, long QTc or BBB Usually admit: Sudden LOC with injury, palpns, exertional syncope Frequent episodes Suspicion of arrhythmia or CAD Mod to sev postural hypotension Over 70y Don’t need to admit: The rest!
+ Course of action for Case 1 Admit Stop ramipril Watch BPs ECHO Home after 24h
+ What we must do Thorough history ruling out each potential serious diagnosis Exam focussing on evidence of arrhythmia, heart failure, BP, aorta assessment and neuro concerns Focussed ix: ECG, post BP, bloods If home – consider GP ref for ECHO
+ Case 2 43y man Chest pain – severe for 20 mins but by arrival resolved ECG and obs at triage normal HTN for past 5y Smoker
+ More info? Pain was chest and between shoulder blades, very sharp, 10/10 then settled Pain in right arm earlier Hasn’t been taking BP meds as thought caused impotence
+ QT interval: beginning of QRS complex to end of T wave most machines will calculate the QTc = the QT length corrected to a rate of 60bpm normal = less than 450 (or thereabouts!)
+ Young fit collapses Most are vasovagal…. Less common in males…. Just think of 1. Arrhythmias – familial sporadic or iatrogenic long QT predisposes to ventricular arrythmias and cardiac arrestr 2. Cardiomyopathies
+ HOCM: Young fit men/boys Sudden collapse whilst exercising Due to obstructed outflow of blood from LV to aorta Demand exceeds supply Syncope May present as VF or PEA arrest
+ Summary Thought about 3 cases that may walk in to minors That may not ring alarm bells Need to: Have an open mind Know differential diagnosis Know the ED tests that will rule out the rare and serious diagnoses ANY QUESTIONS?