Syncope investigations

[Melclin]

How much does syncope need to be investigated and by whom?

I ask this because we seem to be encouraged to be overly risk adverse with syncope and we do see a fair bit of it.

Traditionally, paramedics here have been keen to write apparently healthy post-syncope pts of as having suffered from a "vasovagal", despite having a relatively poor understanding of what that really means. This has got paramedics into trouble on occasion and we have been warned: "beware the healthy syncope pt".

The more I learn about it though, the more I think certain syncope pts don't need transport and it seem like this might be one of those areas where good education and some keen history taking might avoid an unnecessary trip to the ED.

Do your syncope pts have an automatic trip to ED?
How deeply do feel syncope should be investigated?
If the history is consistent with a neurocardiogenic/vasovagal etiology and the pt is otherwise healthy, do you d/c them?

 

[Smash]

The term "vasovagal" gives me the screaming :censored::censored::censored::censored:s when it is bandied about as a catch-all phrase for anyone who faints. It's a diagnosis of exclusion and one I'm not keen to see used in the field. Even patients who are diagnosed with vasovagal syncope have an increased risk of death within the next 3 years.

Syncope is serious and does need investigated in most cases. How this investigation is carried out depends on how comfortable you are in referring patients on to their primary care physician.

The San Fran Syncope rule is quite sensitive for identifying patients who are at high risk for serious adverse events within 7 days. Anyone with history of CHF, SOB, hypotension and something else that I can't remember or be bothered looking up, is at high risk.

Personally I'm very wary of old people, people with co-morbidities or people of Asian descent who faint.

 

[Melclin]

Perhaps I should have said uncomplicated syncope

The term "vasovagal" gives me the screaming :censored::censored::censored::censored:s when it is bandied about as a catch-all phrase for anyone who faints. It's a diagnosis of exclusion and one I'm not keen to see used in the field. Even patients who are diagnosed with vasovagal syncope have an increased risk of death within the next 3 years.

Syncope is serious and does need investigated in most cases. How this investigation is carried out depends on how comfortable you are in referring patients on to their primary care physician.

[highlighted for emphasis]

The San Fran Syncope rule is quite sensitive for identifying patients who are at high risk for serious adverse events within 7 days. Anyone with history of CHF, SOB, hypotension and something else that I can't remember or be bothered looking up, is at high risk.

Personally I'm very wary of old people, people with co-morbidities or people of Asian descent who faint.

So is psychogenic hyperventilation (a diagnosis of exclusion). But sometimes there are situations in which one can reasonably forgo the ABG, helical CT, CXR, lung function, FBE etc.

The San Fransisco Rule is pretty useless prehospital wise. And judging by subsequent validation studies, it might not be much use in hospital either Seriously though, the San Fransisco Rule is good at what I'm getting at. Reducing over triage of low risk pts.

Whats most? Cardiopulmonary co-morbidities are a pretty obvious must for further investigation. Nanna down syncopes too. Syncope + age or syncope + *obvious worrying sign/symptom* is a different kettle of fish. The mistake here is that I just said syncope when I meant 'what criteria makes a person a low risk patient in your judgment'. The point of my question gets at what system people have for choosing between say d/c, d/c with GP or ED for people with uncomplicated syncope.

A young bloke is standing in the sun all morning without eating and drinking. Has a hx of two previous syncopal episodes in similar situations that were investigated and not found to be serious. No meds/med hx. Prodrome and event hx consistent with neurocardiogenic syncope. I feel comfortable saying you're okay, stay out of the sun, have water + lunch, see your GP if you're concerned.

Of course nanna with her CHF, 3 MIs, COPD and a 16 item med list is going to hospital, but I'm hardly talking about her. Its the people in-between our young bloke and nanna (more towards the young bloke end) that I'm interested in.

 

[Veneficus]

How much does syncope need to be investigated and by whom?

I ask this because we seem to be encouraged to be overly risk adverse with syncope and we do see a fair bit of it.

Traditionally, paramedics here have been keen to write apparently healthy post-syncope pts of as having suffered from a "vasovagal", despite having a relatively poor understanding of what that really means. This has got paramedics into trouble on occasion and we have been warned: "beware the healthy syncope pt".

The more I learn about it though, the more I think certain syncope pts don't need transport and it seem like this might be one of those areas where good education and some keen history taking might avoid an unnecessary trip to the ED.

Do your syncope pts have an automatic trip to ED?
How deeply do feel syncope should be investigated?
If the history is consistent with a neurocardiogenic/vasovagal etiology and the pt is otherwise healthy, do you d/c them?

new syncope vs old syncope.

I think the answer to your question is going to be determinded by what you will consider an acceptable loss.

If the syncope is new, it needs to be worked up by the doctor in an ASAP sort of way.

If the syncope is old, are you comfortable attributing it to mismanagement and an isolated incident, accepting there could be a new etiology of syncope?

Personally, I think that the investigation to warrent not going to the ED is possible, but there would have to be considerable history and physical exam skills of experienced providers. I don't think it could be effectively done by anyone.

Then how much time/effort will it save? Is it worth it in your system?

I agree about a dx of exclusion, but the list of exclusion spans multiple organ systems. Cardiac, vascular, neuro, renal, endocrine, respiratory comes immediately to mind but is not all inclusive.

IN all the places I have been, a trip to the ED and let the doc sort it out is a better use of resources.

 

[Aidey]

For me the things I focus on are situation, baseline health and current assessment.

Healthy 20 year old female is kneeling on the floor for 20 minutes and then has a syncopal episode after standing up and now feels fine - Not to concerning.

50 year old male with HTN and high cholesterol has a syncopal episode while standing up, and now feels a bit "off". - More concerning.

80 year old with 20 medications and every diagnosis that is a 3 or 4 letter acronym has a syncopal episode while sitting and now her BP is low - I'm fairly concerned.

Heck, anyone who has a syncopal episode while sitting lands on my very concerned list.

 

[Sam Adams]

I believe pre-hospital providers should be looking to place syncope into two categories when thinking about referring someone to their PCP or letting them refuse care. Explainable and non-explainable. Is there a Hx of fluid loss? Were they baring down and busting a grumpy (moving their bowels)? Stand up too fast? Poor PO? Excessive expenditure of energy in temperature extremes? Etc.

Where as the "I was feeling fine right up until the point I woke up on the floor" ones, warrant further investigation by us and definitive care.

Obviously the persistently symptomatic pt buys a ride.

 

[mgr22]

Syncope doesn't always lead to a trip to the ED, but I think it should always lead to a recommendation by the EMT or medic that the patient allow transport to an ED for further evaluation by a physician.

I also think EMS providers who feel they can consistently, reliably differentiate syncope cases not needing an MD's intervention are overestimating their knowledge and training.

 

[jrm818]

The San Fransisco Rule is pretty useless prehospital wise. And judging by subsequent validation studies, it might not be much use in hospital either Seriously though, the San Fransisco Rule is good at what I'm getting at. Reducing over triage of low risk pts.

I agree with you in principle - it's very desirable to delineate between those who have disease and those who do not. However, I think the apparently failure of the SF rule to be validated tells us quite a bit about the disease we're looking at, and the difficulty of ruling in or out disease.

Should we really be surprised that the SF rule isn't so hot. That was an attempt to use a mathematical formula to create a set of variables that draw a line between "sick" or "not sick" in a very complex and heterogeneous set of diseases. Its no shocker that there is no such line.

My brief reading of the data suggests that physician judgment was much more sensitive in the failed validation trial. I think that makes sense: as great as math is, a human being is going to be much better at accounting for multiple interlinked variables in an individual patient. The question really is: are paramedics as good as physicians at ruling in or out disease.

Well, probably not. That said, I wonder, with you, if there are cases where there is so obviously no serious disease that paramedics can safely make the determination. Perhaps with the education level in Australia that could happen. With the current state on this island, that would rely on someone writing a protocol, which, in reality, is no different than a decision rule and likely subject to the same level of failure.

The ability to triage to PCP may be the most valuable option, it seems to me.

 

[LucidResq]

IN all the places I have been, a trip to the ED and let the doc sort it out is a better use of resources.

What do you think about an amusement park or any large outdoor event... where people who probably wouldn't have even called 911 had they been in a different setting end up in the first aid clinic because they're in public?

We had at least one syncope (sometimes 10 or more) pretty much every day the temperature was above 80 and sent very, very few of those patients to the hospital.

 

[TomB]

All syncope patients should receive cardiac monitoring and a 12-lead ECG and be evaluated for arrhythmia, ischemia, prolonged QT, delta waves, hypertrophic cardiomyopathy, and Brugada.

 

[Veneficus]

What do you think about an amusement park or any large outdoor event... where people who probably wouldn't have even called 911 had they been in a different setting end up in the first aid clinic because they're in public?

We had at least one syncope (sometimes 10 or more) pretty much every day the temperature was above 80 and sent very, very few of those patients to the hospital.

So did I,

but the syncope was probably very accurately Dx as a volume depletion.

When you know what causes the syncope, there is very little reason to do an expensive workup each time.

When you have an 70 y/o with all kinds of comorbidities, then a more detailed workup is indicated. If you were doing a treat and release for them, I would say you were gambling.

 

[LucidResq]

When you have an 70 y/o with all kinds of comorbidities, then a more detailed workup is indicated. If you were doing a treat and release for them, I would say you were gambling.

Of course, and the general scheme was, in uncomplicated cases, take them into our AC and shade, monitor vitals frequently, talk history, po fluids slowly, and see how they respond. Anyone with abnormal vitals, any concerning history, or anyone that didn't respond appropriately to the simple treatments was a candidate for transport.

The other thing I'd be wary of is whether or not bystanders are able to accurately distinguish between syncope and a seizure. I got pulled by some bystanders who said "this kid passed out" but coming up to him it soon became evident that the 8 yo was postictal and his parents provided information that he had no hx of seizures and actually bumped his head earlier in the day.

I think some people just don't know what seizures are and just automatically relate that type of event to "passing out."

 

[Veneficus]

Of course, and the general scheme was, in uncomplicated cases, take them into our AC and shade, monitor vitals frequently, talk history, po fluids slowly, and see how they respond. Anyone with abnormal vitals, any concerning history, or anyone that didn't respond appropriately to the simple treatments was a candidate for transport.

What the real question is:

"If EMS providers can provide treat and release when they are at an amuzement park or large sporting event, why can they not do it any other time?

The other thing I'd be wary of is whether or not bystanders are able to accurately distinguish between syncope and a seizure. I got pulled by some bystanders who said "this kid passed out" but coming up to him it soon became evident that the 8 yo was postictal and his parents provided information that he had no hx of seizures and actually bumped his head earlier in the day.

I think some people just don't know what seizures are and just automatically relate that type of event to "passing out."

I take everything bystanders tell me with a grain of salt. Most very accurately describe what they saw, but what they say isn't always what they meant.

 

[Sam Adams]

What the real question is:

"If EMS providers can provide treat and release when they are at an amuzement park or large sporting event, why can they not do it any other time?

I'd be willing to bet it's a resource thing. At parks and large sporting events there are "First Aid" Rooms or tents or what have you (Static resources), where it's possible to: sit with a pt, (again, with an explainable cause of the syncope), treat them appropriately, then cut them loose. In Po-Dunk-Middle-Of-No-Where, the one ambulance for miles around can't, and shouldn't spend that amount of time on scene.

I suppose it "could" happen when and where more resources are available. But again there needs to be an explainable and very probable cause of the event with COMPLETE resolution of the syptoms.

 

[jjesusfreak01]

IMHO...

If the pt has never had a syncopal episode before and it looks like a harmless DFO (standing in line, locked legs, hasn't eaten), then I wouldn't be worried about it, but...

If (and this was a call I had) the pt has these episodes multiple times a year and does not ever go to a doctor, then I will be pressing hard for them to get checked out at the hospital, because it may be the only chance they have to figure out what is going on.

 

[mgr22]

What the real question is:

"If EMS providers can provide treat and release when they are at an amuzement park or large sporting event, why can they not do it any other time?

That's my world. You're right, we're no more or less capable of diagnosing etiologies than other medics. We routinely encourage syncope patients to allow transport for further evaluation by MDs. We're more likely to treat and release because patients are more likely to refuse, and we lack easy access to physicians who might help convince patients to go.

 

[medic403]

syncope

"Syncope is serious and does need investigated in most cases. How this investigation is carried out depends on how comfortable you are in referring patients on to their primary care physician.


Personally I'm very wary of old people, people with co-morbidities or people of Asian descent who faint.[/QUOTE]

I also agree. Syncope means there was a disturbance in the brain long enough for them to go unconscious. Who are we to say a healthy person had a vaso vagal response? How do we know they did not have a run of Vtach?
There are many reasons of syncope, and prehospitally we can not rule them all out. If a pt refuses transport by EMS, then have some one take them to seek medical attention. Do a follow up as well to see if they did seek medical care. I do treat syncope very serious, I don't care of age, race, gender, or size. They all receive the same type care from me.

 

[Veneficus]

So how does all this play out?

Once again, I find myself educating people that the ED is not the definitive care resource. Just because you take a person to the ED does not mean:

a. They will be admitted for further testing
b. They will receive any sort of care for the condition they are ultimately dx with.

So let's say you take patient X to the ED for syncope, for brevity, we will just say this is the first episode in a 45 y/o male with no other history, meds, or complaints.

They will likely run some labs, which for our argument are all mid range of normal. A chest xray with no significant findings, maybe even a CT.

With no acute changes noted, they are likely monitored and set up with a follow up with cardiology and sent on their way. There will be no transesophageal echo, no halter monitor, etc.

In the grand scheme a few more tests than EMS has that basically yields nothing and costs a lot.

Now you can alter this age and sex up and down, but unless you have a considerable comorbidity, an acute finding, or an extremis of age, they are not anymore likely to get admitted and the ED simply cannot offer more indepth diagnostics or treatment.

I have never even heard of an ED referring somebody to cardiac surgery. Always to cardiology first. Who may or may not feel the situation significant enough for an admisssion and immediate testing.

Now I will concede that some hospitals may admit anyone who walks through the door because they need the money and have the capacity, but that is not a decision made on patient condition/need, it is made by what is economically best for the hospital.

Likewise it is absolutely irresponsible to fill up a cardiology ward with a bunch of volume depleted amuzement park goers, novice marching band members, or every sportsman who feels a little "lightheaded."

Let us be real clear on the deliniation of the inability of the provider vs. the medical needs of a patient because "what if?"