1. EMERGENCY
Awn khawaldeh

2. Syncope • Syncope is a symptom, not a diagnosis
• Transient loss of consciousness with return to baseline neurologic function
• Hypoperfusion to the cerebral cortex and RAS for 8-10 seconds

3. Causes of Syncope
• Neural mediated • Orthostatic hypotension • Cardiac • Neurologic • Medication related

4. Causes-Orthostasis
• A drop in blood pressure associated with symptoms • Is considered positive if the systolic blood pressure drops more than 20 mmHg or the blood pressure is below 90 mmHg regardless of symptoms • Should be taken after the patient is supine for 5 minutes and taken at 1 and 3 minutes after standing • Could also be secondary to acute blood loss

5. Causes-Neurologic
• Could include TIA, seizure, migraine headache • Not uncommon to have brief convulsive activity if the brain is hypo-perfused • Confusion after the event for longer than 5 minutes suggests seizure • Tongue biting and incontinence also suggest seizure

6. Causes-Cardiac Related
• Arrhythmia – Both tachy and brady arrhythmias • Ischemia • Valvular “Patients with cardiovascular causes have a strikingly higher incidence of sudden death than patients with a noncardiovascular or unknown cause.”

7. Causes-Medication Related
• Medication related-prone to arrhythmia – Anti-arrhythmics – Anti-anginal medications – Anti-hypertensive medications – Diuretics

8. Causes-Neurally Mediated
• Vasovagal (occurs because your body overreacts to certain triggers)
– Associated with sense of warmth and/or nausea
– Often associated with extreme emotional distress
– Can be associated with prolonged standing
The vasovagal syncope trigger causes your heart rate and blood pressure to drop suddenly
• Carotid sinus syncope
– Associated with neck pressure or head turning

9. ED Work-up
• EKG • Consider glucose, CBC (hg) • Echo often helpful for admitted patients •neurological examination we should assess for obesity because syncope could occur due to obstructive sleep apnea

10. The San Francisco Syncope Rule to Predict Patients with Serious Outcomes
Chf, Hct, ECG, SBP, SOB •Abnormal EKG •Complaint of SOB •HCT < 30 •SBP < 90 •History of CHF

11. Pulmonary Embolism Most of PE arise from proximal DVT
Risk Factors for Thromboembolism
Family History
Cancer
CHF
Prior thromboembolism
Estrogen use / Pregnancy / Obesity
Low Abdominal/Pelvic surgery/trauma < 6 mos
LE Paralysis/ Immobility / Trauma

12. Symptoms Vs Sign Dyspnea RR > 20/min Pleuritic Pain Rales
Cough Tachycardia
Leg Swelling Loud P2
Leg Pain Temp > 38.5C
Hemoptysis Wheezes
**97% with PE had at least ONE of the following
Dyspnea
Tachypnea
Pleuritic pain

13. Strongest predictors for PE :
Hx of Venous thromboembolism (VTE)
Unilateral Leg Swelling
O2 Sat < 95%
Estrogen Use
Surgery (GA) w/in 4 weeks

14. Diagnostic investigations
In patients presenting with signs or symptoms of PE, carry out the following to exclude other causes:
an assessment of their general medical history
a physical examination
a chest X-ray
If PE suspected use the PE Wells score

15. Wells score for PE

16. D-dimer: usually for low risk patient to rule out thromboembolism
Diagnostic tests
chest X-ray : watermark sign and Hampton hump
ABG : hypoxemia with elevated A-a gradient
CTPA : CT pulmonary angiogram
V\Q scan
D-dimer: usually for low risk patient to rule out thromboembolism
ECG

17. Normal CTPA = no pe
Normal D-dimer = no pe
Normal V\Q scan = no pe

19. 1- Hemodynamically stable
PE management :
1- Hemodynamically stable
LMW heparin or UFH for 5-7 days and oral warfarin for 6 months
if anticoagulation contraindicated we put IVC FILTER then we give anticoagulation
2- Hemodynamically unstable
if patient can arrive hospital within 90 min we don’t give thrombolytic therapy
but if it will take more than 90 min we give the patient thrombolytic therapy