SYNCOPE

ER重點: 排除life-threatening 因素 Syncope protocol Syncope定義： Sudden transient loss of consciousness with loss of postural tone spontaneous return to baseline neurologic function requiring no resuscitative efforts. D/D: Near-syncope Dizziness, Vertigo seizure ER重點: 排除life-threatening 因素

Pathophysiology A drop in cardiac output vasospasm

Etiology (Tintinalli Table 52-1) Reflex-mediated Vasovagal Situration: cough, micturition, defecation, swallow, neuralgia Carotid sins syndrome Orthostatic hypotension Psychiatric Neurological TIA Subclavian steal Migraine Medication Beta-blocker, CCB… Cardiac Structural CV disease VHD Cardiomyopathy Pul. hypertension Myxoma Pericardial disease Aortic dissection Pul. embolism AMI ACS Dysrhythmias Bradycardia Tachycardia

History: 6個P Pre-prodrome activities Prodrome symptoms- visual symptoms, nausea Predisposing factors- age, chronic disease, family history of sudden death Precipitating factors- stress, postural symptoms Passerby witness- what did they see? Post-ictal phase, if any  suggests seizure

Physical Exams Evaluate for trauma Orthostatic vital signs Difference in BP in both arms (aortic dissection or subclavian steel syndrome) Careful CV examination, including murmurs, bruits, and dysrhythmia Rectal exam (GI tract bleeding) Careful neurologic examination

Abnormal ECG: syncope之相關EKG findings: 在評估病人同時應完成 NE complete EKG orthostatic vital signs Abnormal ECG: syncope之相關EKG findings: prolonged intervals(QRS, QTc) severe bradycardia (high degree AV-block) pre-excitation evidence of myocardial infarction low voltage in standard limb leads abnormal conduction syndrome (eg, WPW and Brugada syndrome)

Laboratory Exam: CBC  occult hemorrhage Cardiac enzyme  ischemia Pregnancy test in reproductive age female Electrolytes  profound dehydration or diuretic use D-Dimer  pulmonary embolism

Imaging: Cardiac Echo  structural defects ECG monitoring  dysrhythmia CXR  CHF, dissection Chest CT  pulmonary embolism Head CT  abnormal NE or TIA

Treatment and disposition Admission: specific cause of syncope cardiac Syncope- Arrhythmia, Myocardial infarction, Cardiac tamponade Pulmonary Embolism Neurologic syncope- SAH, Subclavian steal syndrome, TIA Significant hemorrhage- GI bleeding, Trauma, Ruptured internal organ (spleen, ectopic pregnancy, ovarian cyst) Severe dehydration or electrolyte imbalance

Treatment and disposition Admission: unspecific syncope with high risk History of cardiac disease, especially heart failure Persistent SBP< 90 mmHg SOB with event or during evaluation Hematocrit < 30 Older age and associated cormobidities Family history of sudden cardiac death Unexplained syncope Discharge Reflex mediated syncope Orthostatic hypotension(非 hemorrhage induced) Medication related syncope

Protocol

Reference Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice, 6th ed., 2006 Mosby. Tintinalli et al: Emergency Medicine: A Comprehensive Study Guide. 6th ed. 2004 Schaider et al: Rosen & Barkin's 5-Minute Emergency Medicine Consult. 3rd ed. 2007. Lippincott Williams & Wilkins. Linzer, M, Yang, EH, Estes, NA, 3rd, et al. Diagnosing syncope. Part 1: Value of history, physical examination, and electrocardiography. Clinical Efficacy Assessment Project of the American College of Physicians. Ann Intern Med 1997; 126:989. UpToDate, version 15.1 2006