Updated Syncope Document PDF

Syncope Evaluation ================== Definition of Syncope --------------------- Syncope is a transient loss of consciousness due to global cerebral hypoperfusion, characterized by rapid onset, short duration, and spontaneous complete recovery. It is a common clinical problem with varying underly...

Syncope Evaluation ================== Definition of Syncope --------------------- Syncope is a transient loss of consciousness due to global cerebral hypoperfusion, characterized by rapid onset, short duration, and spontaneous complete recovery. It is a common clinical problem with varying underlying etiologies, requiring careful evaluation to determine the cause and associated risk. This document contains the expanded decision tree for syncope evaluation. It includes differentiation between syncope and seizure, and incorporates other high-risk diagnoses such as AAA (abdominal aortic aneurysm), ectopic pregnancy, subarachnoid hemorrhage, and pulmonary embolism (PE). The decision tree diagram is included below. Key Features of the Decision Tree --------------------------------- 1\. \*\*Red Flags:\*\*\ - Chest pain, palpitations, or exertional syncope.\ - Family history of sudden cardiac death.\ - Abnormal ECG or a history of heart disease.\ \ 2. \*\*Differentiation between Syncope and Seizure:\*\*\ - Syncope: Rapid recovery, prodrome (e.g., sweating, nausea).\ - Seizure: Postictal confusion, tongue biting, or prolonged confusion.\ \ 3. \*\*Other High-Risk Diagnoses:\*\*\ - Abdominal aortic aneurysm (AAA).\ - Ectopic pregnancy.\ - Subarachnoid hemorrhage.\ - Pulmonary embolism (PE):\ - Use the PERC (Pulmonary Embolism Rule-Out Criteria) score following the wells score to evaluate pretest probability before ordering a D-dimer test.\ - If the PERC score is negative, no further testing may be required.\ - Reference: Kline, J. A., et al. (2008). \'Prospective multicenter evaluation of the Pulmonary Embolism Rule-Out Criteria.\' \*Annals of Emergency Medicine\*, 52(2), 176--187.\ \ 4. \*\*Disposition Recommendations:\*\*\ - High-risk cases: Hospital admission or urgent evaluation.\ - Low-risk cases: Reassurance and outpatient follow-up. Neurally Mediated Syncope\ \ Types and Characteristics\ 1. Vasovagal Syncope\ - Known as \"common faint,\" involves the \*\*3 Ps\*\*:\ - Posture: Often occurs while standing.\ - Prodrome: Sweating, nausea, warmth.\ - Precipitating trigger: Emotional stress or hot environments.\ \ 2. Situational Syncope\ - Triggered by specific activities involving changes in bodily functions:\ - \*\*Defecation\*\* or \*\*swallowing\*\*.\ - \*\*Micturition syncope\*\* (urinating).\ - \*\*Cough syncope\*\*: Associated with recurrent episodes due to coughing.\ \ 3. Carotid Sinus Syncope\ - Occurs with neck stimulation, e.g., turning the head or wearing a tight collar. Orthostasis Drug induced - alpha blockers, antihypertensives, diuretics Postural changes- standing up quickly Underlying medical conditions- diabetic. polyneuropathy, Parkinson\'s , other systemic illness\ \ Evaluation Framework\ The decision tree approach integrates the identification of neurally mediated syncope and orthostasis with:\ - Differentiation: Clarify syncope versus seizure based on symptoms like prodrome, postictal confusion, or tongue biting.\ - High-risk diagnoses: Rule out cardiac, vascular, or neurological causes.\ - Guideline-based tools: Utilize validated criteria such as PERC for PE evaluation. -While it is useful to know of San Francisco chess score and Canadian syncope rules, note that there is no validated rules in the gp setting for syncope and these rules are actually no better than clinical gestalt.\ \ Management\ - \*High-risk\*: Urgent care or hospitalization.\ - Low-risk: Reassurance and outpatient follow-up. References ---------- 1\. European Society of Cardiology (ESC) Guidelines (2018):\*\*\ - Guidelines for the diagnosis and management of syncope.\ \ 2. American Heart Association (AHA)/American College of Cardiology (ACC) Guidelines (2017):\*\*\ - Guideline for the evaluation and management of syncope.\ \ 3. Kapoor, W. N. (2000):\*\*\ - Syncope. The New England Journal of Medicine, 343(25), 1856--1862.\ \ 4. Bartoletti, A., et al. (2013):\*\*\ - The diagnostic value of tilt testing in different forms of syncope. Heart, 99(23), 1756--1760.\ \ 5. Kline, J. A., et al. (2008):\*\*\ - Prospective multicenter evaluation of the Pulmonary Embolism Rule-Out Criteria. Annals of Emergency Medicine, 52(2), 176--187.