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 months- cumulative 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. A B C