Is anyone aware of any actual data that the usual dogma of "presence of prodrome" is more likely to exclude cardiogenic/arrhythmogenic syncope? This seems kinda made up - I have had a bunch of patients with a malignant arrhythmia without syncope and they certainly have exactly the same prodrome and symptoms that are supposed to make me feel better about that spell not coming from their heart. What is your practice with syncope where you work? Do you admit these for obs? Discharge with f/u? Get an echo in the ED?
Syncope dogma
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Syncope is one of those complaints that is just too variable to have an algorithm for. I certainly do not use the presence of a prodrome - in isolation - to convince me that a syncopal event is benign.
That being said, I probably admit <5% of my syncope patients who don't have something found on their ED workup that otherwise warrants admission. And most of that 5% are admitted because they're old or heavily comorbid.
That being said, I probably admit <5% of my syncope patients who don't have something found on their ED workup that otherwise warrants admission. And most of that 5% are admitted because they're old or heavily comorbid.
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Old or comorbid = admit.
Young and healthy = discharge.
Remember the rule of 15s.
I admit probably 50-75% of my syncope patients, but the average age at my shop is 65, without exaggeration.
Young and healthy = discharge.
Remember the rule of 15s.
I admit probably 50-75% of my syncope patients, but the average age at my shop is 65, without exaggeration.
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What is the rule of 15? Or is it 15 seconds?
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No, no, no; the five second rule.
The Rule of 15s for Syncope? I thought this was taught everywhere. 15% of the following emergencies will present with syncope as the primary complaint: SAH. TAD. ACS/MI. AAA with rupture. Ectopic pregnancy.
Maybe I'm just tired but what's TAD?
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Thoracic aortic dissection?
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Thoracic aortic dissection/disaster/disease.
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The Ottawa/Canadian rule seems pretty good, but it hasn't been validated yet.
San Francisco syncope rule has been hit or miss with validation.
Presence of prodrome does nothing to rule out serious pathology. A lot of VT patients feel dizzy or lightheaded. So does AF/RVR. Many people get tunnel vision prior to passing out.
A lot of people have increased their workups for PE's in syncope patients based on the Prandoni study (PESIT). That was a selective group of patients (admitted patients only), didn't get testing immediately (up to 48 hours after admission), etc.
San Francisco syncope rule has been hit or miss with validation.
Presence of prodrome does nothing to rule out serious pathology. A lot of VT patients feel dizzy or lightheaded. So does AF/RVR. Many people get tunnel vision prior to passing out.
A lot of people have increased their workups for PE's in syncope patients based on the Prandoni study (PESIT). That was a selective group of patients (admitted patients only), didn't get testing immediately (up to 48 hours after admission), etc.
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How do you increase your workup beyond d-dimer and CT chest? Not snarky.
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Non-selectively ordering D-dimers on every syncope patient.
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Clinical gestalt trumps any algorithmic approach to risk stratification. I routinely apply San Francisco Syncope rules and OESIL (added age > 65 and hx of CAD) for my syncope patients. No risk stratification system is perfect but if I disposition them home, I routinely will document that they were at the very least San Fran syncope negative, or why I thought it was a benign etiology.
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PESIT was a horrible study and I certainly wouldn't use it as justification to order dimers and CTAs on all syncope patients.
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I wouldn't say it's a horrible study. I do have questions regarding how patients with clear signs of DVT or the vitals sign abnormalities reported in the PE positive patients weren't ruled out for PE in the ER, but I understand that in normal practice, things like that frequently do happen. I know the #FOAMed community got into a tizzy over this study about how our IM colleagues were going to force us to CTPA every syncope pt we try to admit, but that reality has not come to fruition, at least where I work. I think there was a lot of faux outrage surrounding this study. My takeaway from it was that it reiterates the fact that many docs forget, that PE should be on the differential of the syncope patient.
I think the people likely to over CTPA everyone are the same type that won't read this study, and the individuals that read the study are the type more likely to be more selective in who they CTPA.
PESIT was covered in the ACP Hospitalist magazine a few months ago. My take home was to consider PE in every syncope regardless of the HPI. I don't expect the ED to do the workup because I can plug in a Well's score and PERC score just as easy as the ED can (insert eye roll at my IM colleges who refuse to actually practice medicine), and complete the workup from there. We've caught a couple of otherwise large asymptomatic (outside of syncope) PEs just from increased awareness.
Also, my view on admitting syncope changed after listening to the Louisville Lecture on syncope. Cardiac syncope has a >10% 6-month mortality rate due to the underlying condition (covered at 26:25). A condition that can have a >10% mortality rate should be an easy admission if there's concern for arrhythmia or structural disease.
Also, my view on admitting syncope changed after listening to the Louisville Lecture on syncope. Cardiac syncope has a >10% 6-month mortality rate due to the underlying condition (covered at 26:25). A condition that can have a >10% mortality rate should be an easy admission if there's concern for arrhythmia or structural disease.
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I consider syncope a legitimate emergency medical condition, and anyone who is more than low-risk usually gets offered/advised cardiac obs and if they decline (which is often the case) it is reflected in documentation.
Risk stratification is based on many different factors and is unique to every patient/event. The work up for syncope varies greatly based on history and risk factors. aka "clinical gestalt".
Risk stratification is based on many different factors and is unique to every patient/event. The work up for syncope varies greatly based on history and risk factors. aka "clinical gestalt".
So I am in agreement with what you said. I hate the patient is X age and has Y complaint/symptom so they get Z but syncope in the olderish usually needs admission. My dispo isn't really hard but the workup is. It is a wide differential and really needs some good thought and explanation for not doing a PE/Dissection study, abdominal CT ect. The frustration for syncope is that no matter what something like 60% still have no clear diagnosis (correct me if I am wrong). So we admit a lot but don't usually find something. Still we are in America. If they die its much better to have them die in the hospital instead of at home. Most people (i.e. jury) thinks the hospital could have done something if they die at home. I will also listen to this when I have a moment.
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Here's what I *don't* do with anyone with syncope: I don't just order the bare minimum, i.e. EKG and fingerstick glucose.... I order shotgun tests and a liter of IV fluids, and see them when everything is back and then go through their labs to show how much we did/checked. And then the IV fluids make them feel better whether it is real or placebo.
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I do the bare minimum for the young syncopal episode with normal vitals, no medical hx, no family hx, who passed out while on the toilet/stood quickly from sitting down or otherwise non-concerning story. What are you expecting the labs to show you, or is it more like therapeutic lab work? ACC/AHA states the only real requirement is an ECG for the non-concerning syncope case, as does ACEP clinical policy on syncope in ED.
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Therapeutic lab work that comes back by the time I see the patient. And the iv fluids make them feel like something was done. I dunno, I feel patients love labs and fluids. They absolutely hate "what? You didn't do anything?"
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I do this all the time, too.
"Your labs and studies are all back. Fortunately, there's no evidence of anything pressing that I need to keep you in the hospital for. Unfortunately, there's also no evidence that tells me what happened to cause you to pass out today. That's not actually a bad thing, though.... yadda, yadda...."
Has anyone started doing CTPA/CTA on their syncope patients yet? What have you found?
PESIT doesn't pass the sniff test, predominantly because I haven't seen syncope patients coming back dead from missed PEs yet.
PESIT doesn't pass the sniff test, predominantly because I haven't seen syncope patients coming back dead from missed PEs yet.
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I hope not. Lets use some good clinical sense.
Syncope + PERC/Wells + Clinical suspicion +/- D dimer will get you a CTPA, not just "Syncope = CTPA".
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What about unexplained syncope = d-dimer. This seems to be where I'm headed with this but it might be excessive.
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Read what I wrote again.
Syncope = d-dimer should mean exactly the same thing to you as syncope = CTPA. D-dimer is a test for a patient who you think is low or moderate risk but you would order a CTPA if a dimer was not available.
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Here's my usual practice for unexplained syncope. There is very little good quality evidence and you have to decide how much risk you and your patient population are comfortable with.
All patients get ECG
All exertional syncope gets admitted
Very low risk, non-exertional syncope with normal ECG gets no labs unless there's a specific reason to do labs, and outpatient workup
Low-moderate risk gets a discussion on the risks/benefits and obs or discharge depending on the patient's preference and availability of adequate outpatient follow up
Higher risk or any concern for structural abnormality gets obs or admit
The risk stratification is all in my head and depends on age and co-morbidities mostly. I don't use the presence or absence of prodrome to make the decision, but it does probably bias me when I'm deciding on the risk level. All syncope that occurs on Sunday in church is automatically low risk.
All patients get ECG
All exertional syncope gets admitted
Very low risk, non-exertional syncope with normal ECG gets no labs unless there's a specific reason to do labs, and outpatient workup
Low-moderate risk gets a discussion on the risks/benefits and obs or discharge depending on the patient's preference and availability of adequate outpatient follow up
Higher risk or any concern for structural abnormality gets obs or admit
The risk stratification is all in my head and depends on age and co-morbidities mostly. I don't use the presence or absence of prodrome to make the decision, but it does probably bias me when I'm deciding on the risk level. All syncope that occurs on Sunday in church is automatically low risk.
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The PESIT trial looked at syncopal patients who were admitted to Italian hospitals. That is likely a significantly different population than US ED patients.*
Order a d-dimer because you think that the patient in front of you might have a PE, not because of PESIT.
*My point being that I'd guess it's a lot harder to get admitted to an Italian hospital than it is to syncopize your way into a US ER.
Order a d-dimer because you think that the patient in front of you might have a PE, not because of PESIT.
*My point being that I'd guess it's a lot harder to get admitted to an Italian hospital than it is to syncopize your way into a US ER.
