“I passed out”

Frederick Korley M.D., Department of Emergency Medicine

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

EKG

Disposition

Will you admit or you send the patient 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