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You evaluate a 44-year old woman for syncope. She was walking from her desk at work to the coffee room when she was witnessed by coworkers to slump to the ground. She immediately regained consciousness, and answered questions normally at that time. She had no prodrome of palpitations, chest pain, shortness of breath, light headedness or dizziness. She did not injure herself in the fall. • The patient has no chronic medical problems and is on no medications. She has no history of syncope or seizures. • Review of systems is entirely negative. • Physical examination, including orthostatic vital signs, is normal.
Which of the following is indicated in her initial evaluation? A) ECG B) 2-D echocardiogram C) holter monitoring D) bilateral carotid dopplers E) A, B and C F) All of the above
Which of the following is indicated in her initial evaluation? A) ECG B) 2-D echocardiogram C) holter monitoring D) bilateral carotid dopplers E) A, B and C F) All of the above
Syncope • 3% of ED visits • 100,000 / yr • $2.4 Billion for hospitalization • mortality (15 year) • If cardiac cause - 30% • non-cardiac - 12% • Causes • neurally-mediated 24% • unknown 34% • arrhythmia 14% • non-CV 12% • orthostatic 11% • structural 4%
Syncope • Initial evaluation of the patient with syncope (especially < age 45 with no risk factors): • history, exam, EKG • HX • cardiac hx • family hx • medications • Exam • Orthostatics • cardiac exam • neurologic exam • carotid sinus massage (3 sec pause or 50mm bp drop is +)
Syncope recommendations • American College of Emergency Physicians (ACEP): • “high risk” need further evaluation (older than 60, cardiovascular disease) • younger than 45 years without cardiovascular disease or other risk factors should be considered at low risk • The European Society of Cardiology • recommends a similar evaluation and provides guidance regarding clinical symptoms that suggest specific causes of syncope
Syncope recommendations • Other testing (ECHO, holter, event monitor, tilt table testing, carotid dopplers) are not recommended as initial evaluation of syncope • Tests should be guided by abnormalities on history, exam, or ECG. OBJECTIVE:Evaluate a first syncopal episode in an adult with normal findings on initial physical examination.
