Emergency Department Guidelines COLLAPSE? CAUSE / SYNCOPE. Version x (x 201x) Review date: x 2014 Page 1 of 5

Transcription

1 COLLAPSE? CAUSE / SYNCOPE Review date: x 2014 Page 1 of 5

2 KEY POINTS: Do not use this guideline for mechanical falls Definition: Syncope is a transient loss of consciousness with an inability to maintain postural tone followed by a spontaneous recovery General considerations for ED management: Priority is to recognize and treat the immediately life threatening conditions. A good history and physical examination will give you a diagnosis in about 40% of cases Very few ED investigations are useful to determine the cause Instead of establishing a diagnosis in the ED the management should focus on risk assessment Causes of syncope: 70 % Non-cardiac 11 % Cardiac 14% Unknown - vasodepressor (37%) - Arrhythmia (7%) - orthostatic (24%) - ACS (1.5%) - neurological (5%) - Ao Stenosis (1%) - psychiatric (2%) - PE (1%) - Carotis Sinus Hyperaesthesia (1.5%) Since the mortality is the worse in the group of cardiac syncope, the aim is to identify these patients in the ED and refer them for specialist care and follow up. RED FLAGS: - Abnormal ECG - Known structural heart disease (CAD, AoStenosis, Cardiomyopathy) - Prodroma is missing or very short (< 1 min) - Chest pain or palpitation before collapse - Syncope on exertion - Injury during the fall - Anaemia - Repeated syncope within a short period of time - Family history of SCD Review date: x 2014 Page 2 of 5

3 History: Take detailed history from the patient and the witness of the event. Past medical history, incl. family history Prodroma (activity before the collapse, duration of prodroma, symptoms, etc) Collapse (duration, seizure activity, skin color, breathing pattern, enuresis, etc) Recovery (duration, confusion, amnesia, symptoms, etc) Physical examination: - Signs of heart disease (LVF, heart murmur, PM, etc) - Heart rate, pulses, blood pressure standing and lying - Signs of tongue bites - Signs of incontinence - Full neurological status - Signs of anaemia, GI bleeding - Signs of injuries (C-Spine!) Investigations: - 12 ECG is mandatory - Bloods (FBC, U&E, bhcg) - Postural BP No other investigations in the ED were proved to be useful for risk assessment or diagnosis. In some selected cases the following studies might be needed: - Urine dipstick (HCG, UTI - elderly patients) - Chest X-Ray (chest infection, PE) - CT head (SAH?) - CTPA (PE?) - Other biochemistry or haematology (renal, thyroid, clotting studies) - Echocardiography (valvular disease or cardiomyopathy) - Ultrasound (free fluid?) - Tilt Table Test (Vasovagal?) - Exercise Tolerance Test (CAD?) When the 12 ECG is considered abnormal after syncope? - Any kind of arrhythmia - Frequent ventricular premature beats - ST - T changes (signs of ischaemia) - AV block - Bundle brunch block - Long QTc (>500) - Brugada (ST elevation in V1-V3, a kind of RBBB pattern) In case of postural BP drop - carry out rectal examination - carefully assess for signs of occult bleeding Review date: x 2014 Page 3 of 5

4 - look for possible cause of hypovolaemia - Treat the cause and refer as appropriate Acute life threatening conditions Usually easy to recognize in the ED. These patients need immediate ED management according to the appropriate protocols: Start stabilization in the ED and refer patients to the appropriate specialty. Ask for senior help early. - Arrhythmias - ACS (with or without ST elevation) - PE - SAH - Ectopic pregnancy - GI bleeding - Repeated seizure Risk assessment High risk patients need to be referred to the Medical Team - Patients with a history of CAD, valvular heart disease, cardiomyopathy OR - Patients with signs of LVF OR - Chest pain before or after the syncope OR - Abnormal ECG OR - Exertional syncope OR - Anaemia OR Medium risk patients: discuss with ED senior, consider admission. - Syncope with injury or repeated episodes OR - Age > 45 otherwise healthy AND - No ECG sign AND - No clear inciting event Low risk patients could be discharged home with or without follow up by GP - Age < 45 AND - Prodrome suggests vasodepressor or orthostatic etiology Elderly patients with syncope must always be considered as in risk. Discuss with senior to decide if admission is needed. Subject Applies to Date issued Status Version Review date This policy lays out guidance in relation to Collapse of unknown origin / Syncope All staff working in the ED at East Surrey Hospital Discussion Review date: x 2014 Page 4 of 5

5 Responsible person Authorised by Related documents Documents replaced Dr J Webb, Lead Consultant in Emergency Medicine Dr C Dioszeghy Consultant in EM / Guideline Medical Directorate Healthcare Governance Committee NICE Guideline 109: Transient loss of consciousness (Blackouts) management in adults and young people Aug 2010, ESC: Guidelines of the diagnosis and management of syncope Review date: x 2014 Page 5 of 5