“i passed out”
DESCRIPTION
“I passed out”. Frederick Korley M.D., Department of Emergency Medicine. Top 5 causes of Syncope. 1. Unknown. 36.6%. 2. Vasovagal. 21.2%. 3. Cardiac. 9.5%. 4. Orthostatic. 9.4%. 5. Medication. 6.8%. Study participants from the original Framingham Heart Study and in the Framingham - PowerPoint PPT PresentationTRANSCRIPT
Top 5 causes of Syncope
6.8%
9.4%
9.5%
21.2%
36.6%
Medication5.
Orthostatic4.
Cardiac3.
Vasovagal2.
Unknown1.
Study participants from the original Framingham Heart Study and in the FraminghamOffspring Study who underwent routine clinical examinations between 1971 and
1998. 7814 patients followed 822 reported syncope.
Soteriades ES, Evans JC, Larson MG, Chen MH, Chen L, Benjamin EJ, Levy D. Incidence and prognosis of syncope. N Engl J Med. 2002 Sep 19;347(12):878-85.
Framingham Heart Study
Soteriades ES, Evans JC, Larson MG, Chen MH, Chen L, Benjamin EJ, Levy D.
Incidence and prognosis of syncope. N Engl J Med. 2002 Sep 19;347(12):878-85.
“Persons with cardiac syncope are at increased risk for death from any cause
and cardiovascular events, and persons with syncope of unknown cause are
at increased risk for death from any cause. Vasovagal syncope appears to
have a benign prognosis.”
Note: There is a very nice table in the article: PubMed
San Francisco Syncope Rule – Decision Tree
Quinn JV, Stiell IG, McDermott DA, Sellers KL, Kohn MA, Wells GA. Derivation of the San Francisco Syncope Rule to predict patients with short-term serious outcomes. Ann Emerg Med. 2004 Feb;43(2):224-32.
CHESS
Predictors of Short-Term Serious OutcomesAbnormal ECGShortness of BreathSystolic Blood PressureHematocritCongestive Heart Failure
Very nice figure in Article: PubMed
Don’t forget to…..
Confirm that patient is at baseline mental status
Examine c-spine for tenderness Look for bruises, cuts, tongue laceration Listen for new murmur Rectal exam for those who may have GI bleed
as the source of their syncope Tetanus shot for those who need one If female, make sure she is not pregnant Make sure patient is able to walk before you
think of sending them home
ACEP Clinical Policy on Evaluation and Management of Syncope - 2001
What data help to risk stratify patients with syncope?– Age > 60 + CAD = high risk – Age < 45, no CAD = low risk– Physical exam signs of CHF = high risk
Who should be admitted after a syncopal event?– History of CHF or ventricular arrhythmias– Associated chest pain or symptoms compatible with ACS– Signs of CHF or valve disease on exam– EKG with ischemia, arrhythmia, prolonged QT, BBB– Consider admission for: age > 60, h/o CAD, congenital
heart disease, FHx of sudden unexpected death, exertional syncope in younger patient
Torsades de pointes
A form of polymorphic V. tach that occurs in the setting of prolonged QT interval, T wave abnormalities or increased U wave amplitude
Changing morphology of QRS complexes that seem to twist around an imaginary baseline
Corrected QT(QTc) > 440ms Usually self terminating but can result in V. fib
Causes of long QT and Torsades de pointes
Gowda RM, Khan IA, Wilbur SL, Vasavada BC, Sacchi TJ. Torsade de pointes: the clinical considerations. Int J
Cardiol. 2004 Jul;96(1):1-6.
There are significant causes of prolonged QT syndrome
CongenitalAcquired:
MedicationsElectrolytesCardiac diseaseStarvation …to name a few
Nice Table in article:PubMed
Commonly used drugs that can prolong QT
Antiarrhythmics Mainly Class 1A, 1C and III eg: Procainamide, flecainide, Sotalol, Ibutilide, amiodarone
Antimicrobialse.g.: Macrolides, fluoroquinolones, azole antigungals, ampicillin, bactrim
Antihistaminese.g.: Benadryl, Hydroxyzine
Antidepressantse.g.: doxepin, fluoxetine, paroxetine, imipramine, clomipramine, citalopram
Antipsychoticse.g.: Haldol, droperidol, lithium, chloral hydrate, chlopromazine, prochloperazine
Othersfosphenytoin, hydrochlorothiazide, tamoxifen, antimigraine agents, furosemide, reglan, cisapride, cocaine
Gowda RM, Khan IA, Wilbur SL, Vasavada BC, Sacchi TJ. Torsade de pointes: the clinical considerations.
Int J Cardiol. 2004 Jul;96(1):1-6.
Risk factors for drug induced torsades de pointes
Gowda RM, Khan IA, Wilbur SL, Vasavada BC, Sacchi TJ. Torsade de pointes: the clinical considerations.
Int J Cardiol. 2004 Jul;96(1):1-6. Nice Table in article:PubMed
Congenital long QTFemale GenderElectrolyte abnormalitiesDiureticsBradycardiaEtc. etc.
Methadone induced Torsades de pointes
Can occur with increasing doses of methadone, polysubstance abuse, taking other drugs that also prolong QT, etc
One Swiss paper reports 5 cases
Sticherling C, Schaer BA, Ammann P, Maeder M, Osswald S. Methadone-induced Torsade de pointes tachycardias.
Swiss Med Wkly. 2005 May 14;135(19-20):282-5.
Treatment of Torsades
IV, O2, Monitor, pacer pads Stop offending drugs Check electrolytes including mg Give Magnesium 2g over 1-2 mins, may
repeat in 15 mins if necessary May use isoproterenol or atropine to increase
HR and shorten QT (atropine may be easier to get in ED, ISO is contraindicated in ischemic heart and congential long QT)
May overdrive pace with ventricular rate >90 Replete K if low