SYNCOPE a symptom, not a diagnosis Clinical cases
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1 SYNCOPE a symptom, not a diagnosis Clinical cases Dr Jaycen Cruickshank Ballarat Emergency Education Updated June
2 Learning objectives they need to be your objectives To apply your knowledge and the information presented in our syncope presentation to these cases To make a diagnosis and safe management plan for each case For ACEM trainees To consider how these cases might appear and be answered in the FACEM exams To write and complete practice questions To realize that good answers in exams are often good answers when in charge of the ED.
3 Case 1 32 yo male, Intravenous drug user Presents with frequent syncopal episodes and? Seizure activity Medication methadone PMHx nil else significant Updated June
4 Case 1 ECG Updated June
5 Case 1 ECG What would you do if this then happened? Updated June
6 Reminder causes of QT prolongation Hypomagnesiuaemia Hypokalamia Hypocalcaemia Na Channel blockers type 1a, TCA Raised ICP Altered conscious state Hereditary Lange Nielsen QT prolongation and deafness Romano Ward - QT only Hypothermia Drugs Updated June
7 Clinical Case 2 19 year old university student Wakes up Sunday morning to the sound of his mobile phone Gets up out of bed, talks for half a minute, then feels funny and blacks out Housemate hears phone and the fall, and runs into the room, he is coming around quickly Referred by GP for ED assessment ECG normal Further assessment and management? Updated June
8 Case 3 middle aged man with fainting episode ED doctor presents to the ED physician Middle aged man with syncope No features to suggest seizure Full assessment and no obvious cause Is there any role for a troponin now and eight hours, how long should we observe for?
9 Case 3 cont. History of presenting complaint. He drove 8 hours Walked into house Went to make cup of tea Then syncopal episode Rapid recovery to normal he heard wife calling the ambulance Background Truck driver Working 2 jobs Very little sleep Past history similar episode Investigation EEG and echo and stress test normal
10 Case 39 year old 39 yo syncopal episode No prodrome No pmhx Normal physical examination Ddx? Updated June
11 ECG Updated June
12 ECG brugada Updated June
13 BRUGADA SYNDROME POLYMORPHIC VT 1/3 will develop 2 nd episode in 2 years Updated June
14 Case 4 16 year old 16 year old with syncope whilst playing basketball at school No prodromal symptoms Awoke after a few seconds No PMHx No FHx Updated June
15 16 year old, syncope while playing basketball Interpret this ECG. Updated June
16 HYPERTROPHIC OBSTRUCTIVE CARDIOMYOPATHY WALL THICKNESS PREDICTOR OF DEATH SUBGROUP WILL NEED AN ICD Updated June
17 Clinical case 5 25 year old with syncope during a lecture No chest pain, no dyspnea No PMHx FHx father died suddenly aged 60 Updated June
18 Further history Further history Syncope while seated May indicate arrhythmia Need more details on what lecture was about, the family history Needs ECG AA Arrhythmia, brugada, CMP Updated June
19 Case 5 cont. What is your diagnosis? Updated June
20 Case 5 cont. WPW Updated June
21 Clinical case 6 68 yo presents following syncopal event following going to the bathroom at 4am Situational Micturition/defecation syncope What if fainted before going to toilet? How does that change things? Updated June
22 Clinical Case 6 45 year old man collapses and takes 6 or 7 minutes to wake up and then he is a little confused Diagnosis? Probably a seizure What further history and examination would be relevant? Updated June
23 Clinical case 7 courtesy emcore.com A 52 year old man is brought to the ED following a collapse. He had been sitting at the kitchen table reading the paper and the next thing he knew he was on the floor He woke with a vice like headache and pins and needles down the left arm He is in AF Updated June
24 Clinical Case 7 further history The patient had a biopsy of his ear where there was carcinoma detected He had just got home following a CT of his neck, looking for lymph node enlargement He had the CT with him and had asked people to look at the report, but no one would tell him what it meant His brother died three months earlier from cancer Updated June
25 Clinical case 7 He was sitting at the kitchen table thinking about dying from cancer and getting very anxious. He got hot and sweaty, felt a little dizzy and collapsed When he awoke, he did have a vice like headache and pins and needles down left arm. He was in AF He was seeing his cardiologist for AF, which was controlled and he was on aspirin Two previous episodes Previously investigated CT/LP normal, diagnosis migraines was made. Updated June
26 Summary History, exam, ECG Cardiac vs non cardiac Admit for no diagnosis and high risk Older/abnormal ECG, cardiac history including CCF Don t forget to look for other causes E.g TIA, dissection.
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