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Assessing Syncope and Loss of Consciousness

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?.

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Assessing Syncope and Loss of Consciousness

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  1. Assessing Syncope and Loss of Consciousness

  2. 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?

  3. 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

  4. 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.

  5. CAUSES OF SYNCOPE • CARDIAC • Arrythmias • Ischaemia • Obstructive lesions • HOCM • Aortic Stenosis • Mitral Stenosis • NEUROLOGICAL • Seizure (usually easily differentiated) • TIA ( VBI) • SAH

  6. 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

  7. MISCELLANEOUS • Hypoglycaemia • Hyperventilation • Anaphylaxis • PSYCHIATRIC • conversion disorders (50% young pts) • personality disorders

  8. HISTORY • previous syncope • known -IHD,CCF, arrhythmias • medications • blood loss • circumstances of syncope • - prodrome • - position • - exertional • - associated symptoms • Family history

  9. EXAMINATION • Full exam but most importantly • BP (lying, standing) • pulse • PR • Injury assessment • INVESTIGATIONS • BSL • ECG • FBC • UEC

  10. 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)

  11. 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

  12. 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.

  13. So should we admit this man ? • How long do we keep him for ? • What tests and monitoring does he receive?

  14. 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.

  15. 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).

  16. 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

  17. Toxins • alcohol et al • Respiratory • hypoxia/ hypercarbia • Biochemical • eg. Hyponatraemia • Hypo/hyperthermia • Endocrine • hypothyroid

  18. Approach to patient with altered LOC should always be the same. • A B C

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