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EPIX Patient Safety Brief
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Syncope
by Dr. Stephen Colucciello
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“The floor scooped me up where I stood, and I blinked as it hit me.”
― M. Beth Bloom,
Drain You
Introduction
As we know from daily experience, syncope is a frequent complaint in the emergency department, accounting for up to 3% of patient visits.
1
Annually, over 1.3 million Americans visit an ED for syncope
2
and at least one third of these patients are admitted
3
at a cost of over $2 billion dollars
4
.
While the causes of syncope are legion, the majority are benign. Our job is to risk stratify patients into high, moderate/indeterminate, or low risk for complications. We also must carefully search for any fall-related injuries. Such injuries including subdural hematoma or cervical spine fracture may be more dangerous than the syncopal cause.
Syncope Definition
ACEP defines syncope as “symptom complex that is composed of a brief loss of consciousness associated with an inability to maintain postural tone that spontaneously and completely resolves without medical intervention.”
5
True syncope is secondary to global cerebral hypoperfusion and divided into three main categories: reflex or vasovagal syncope, syncope secondary to orthostatic hypotension, and cardiogenic syncope.
6
In the ED, we are most concerned with possible cardiac syncope.
The most dangerous cardiac causes of syncope include tachyarrhythmias such as ventricular tachycardia (VT); brady-arrhythmias such as heart block; left heart-filling problems such as pulmonary embolism and cardiac tamponade; and heart-emptying problems such as severe aortic stenosis. Orthostatic hypotension, while often considered nonthreatening may be lethal if secondary to an aortic catastrophe such as aneurysmal rupture or a massive GI bleed. While reflex (vasovagal) syncope is most common and benign (more than 20%), nearly 10% of events are caused by cardiac syncope (higher in the elderly) and an equal number from orthostatic hypotension. Notably almost 40% of syncope is of undetermined etiology.
7
Presyncope or near syncope is the sensation that a person is going to pass out (or in my ED “fixin to fall out”; as opposed to “done fall out” or true syncope). For years, emergency providers felt comfortable skipping the syncope workup for patients with
near syncope
. This was an error. In a recent study on presyncope, about 5% of presyncope patients had serious outcomes within 30 days of their ED visit. Only two-thirds of the serious etiologies were identified in the ED.
8
Syncope Demographics
Approximately 20% of adults will experience syncope during their lifetime, females more often than males.
9
Older patients have a much higher incidence of syncope and the risk of a cardiac cause increases dramatically. The incidence of syncope increases from 5.7 per 1000 patients per year in their 70’s to almost 4 times that rate for nonagenarians.
10
After age 80 almost 60% of elderly “syncopizers” are admitted to the hospital (justifiably or not).
11
One study showed that 40% of syncopal events in patients 65 or older were cardiac in nature.
12
Differential Diagnosis for Transient Loss of Consciousness
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Syncope Mimics
In addition to distinguishing benign from dangerous causes of syncope, we must discriminate between syncope and numerous mimics. While there are many conditions that masquerade as syncope, the emergency practitioner
must
focus upon the most dangerous.
Potentially Dangerous Syncope Mimics
13
(
adapted
)
:
- Seizure
- Subarachnoid hemorrhage (SAH)
- Hypoglycemia
- Carbon monoxide poisoning
- Hypoxia
- Heat stroke
- TIA/Stroke
- Toxins
- Increased intracranial pressure
- Ruptured AAA
- Aortic dissection
ED Evaluation
Triage
The most important triage intervention for a patient with syncope is to quickly obtain an ECG.
If the patient bypasses triage, the ECG can be obtained on arrival to the room. Patients with abnormal vital signs require cardiac and blood pressure monitoring. The nurse should alert the ED provider regarding unstable patients, start an IV line(s) and obtain blood.
In EDs where nurses have less autonomy, develop a syncope standing order set to ensure a rapid response to potentially unstable patients.
History
History of Present Illness
The history is the most important part of the ED evaluation for syncope.
It can also be the most problematic since a good percentage of patients cannot recall the sequence of events. Make an effort to interview witnesses (by phone is fine) as well as talking to the medics or reading their run report. For institutionalized patients, have your patient rep call the nursing facility and find an eyewitness to speak with you.
If the syncope was witnessed, determine if the patient had a seizure. While several myoclonic jerks can occur with syncope, sustained tonic-clonic jerking, or tonic posturing, suggests a seizure, especially if the collapse is followed by a period of confusion. In a recent study, observers were much better at differentiating between syncope and seizure than patient-reported history (no surprise there).
14
Many emergency providers were taught that urinary incontinence points to a seizure rather than syncope. However, a pooled analysis of data shows that
urinary incontinence cannot distinguish between seizures, syncope or other non-epileptic events
.
15
However,
nausea or sweating before the event,
occurs far more often with syncope, and are useful historical features to
exclude
seizure.
16
Crucial to the investigation is to determine, “What was the patient doing just prior to losing consciousness?”
Red flags for
serious causes of syncope
include:
- During exertion (structural heart disease)
- While sitting or lying down (cardiac syncope)
- Lack of prodrome (arrhythmia)
- Chest pain or shortness of breath (acute coronary syndrome (ACS), pulmonary embolism (PE), or aortic dissection (AD))
- Thunderclap headache (subarachnoid hemorrhage (SAH))
- Sudden flank or back pain (ruptured abdominal aortic aneurysm (AAA))
Syncope upon standing is likely secondary to volume depletion or lack of appropriate postural vascular tone.
Certain scenarios are classically associated with benign “situational syncope”; urination (micturition syncope), cough or sneeze, swallowing, defecating, laughing, and even playing brass instruments (Valsalva-related syncope).
Be cautious about making the diagnosis of micturition or defecation syncope especially in the elderly.
Elderly patients often fall or syncopize
on the way to
the bathroom or
on the way back
from the bathroom or when standing up off the toilet. Clarify if they were in
the act
of urinating or defecating when they passed out.
Carotid sinus syndrome causes syncope when rubbing or massaging the carotid artery and may occur during shaving. The subclavian steal syndrome (SSS) is an unusual etiology of syncope where the vertebral artery flow is reversed into the ipsilateral arm secondary to stenosis of the subclavian artery. The combination of syncope and arm symptoms suggests this diagnosis.
17
If syncope occurred upon standing, determine if patients have a reason for volume depletion such as nausea, vomiting, diarrhea or polyuria. While not every patient with syncope requires a rectal exam, questions regarding melena or bloody stools are appropriate, especially in those with a prior GI bleed, abdominal pain or coagulopathy. Medications are also a major cause of postural syncope as we will see below.
Past Medical History
Obviously you want to know about prior syncopal events and if the workup showed anything. Did they ever wear an ambulatory heart monitor or have an echocardiogram or other cardiac tests? Interestingly, one study showed that in older adults with syncope, a prior history of syncope within the year
does not
increase the risk for serious 30-day events.
18
However, it seems obvious that the more times an elderly patient collapses, the greater risk for injury.
Any heart disease should raise the suspicion of cardiac-related syncope. In ED patients with syncope,
a history of congestive heart failure (CHF) or prior arrhythmias is strongly associated with serious clinical events in the next 30 days
.
19
High risk past medical history includes
20
(
adapted
)
:
- CHF
- Arrhythmias
- Antiarrhythmic medications
- Heart blocks
- Aortic stenosis (AS)
- History of MI or coronary artery disease
- Hypertrophic cardiomyopathy (HCM)
- Cardiac masses (myxoma, tumors)
- Pericardial disease (especially effusion)
- Prosthetic valve
- Pacemaker/ Internal cardiac defibrillator (ICD)
- Aortic disease
- Pulmonary embolism
- Pulmonary hypertension
- Dialysis
The Obligatory Pie Chart
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Family History
A presentation for syncope is one of the few times that family history is essential in the ED. In particular, we want to know if there is a
family history of sudden death
. There are numerous structural and arrhythmogenic heart conditions that are genetic in nature including hypertrophic cardiomyopathy, Brugada syndrome, catecholaminergic polymorphic ventricular tachycardia, and long or short QT syndromes.
21
Medications
A comprehensive medication history is crucial to the syncope work up.
Medications are the number one cause of orthostatic hypotension leading to syncope.
20
Ask if the patient started any new medications or recently increased the dose of an old medication. Ask about missed doses. Patients sometimes “double up” on their medications if they miss a dose, leading to orthostasis.
Antihypertensives (especially diuretics), beta blockers, and psychiatric medications are often implicated. In one study, hydrochlorothiazide, lisinopril, trazodone, furosemide and terazosin were the most frequent causes of medication-associated symptomatic orthostatic hypotension among an elderly population.
Antiarrhythmics are of special concern as they can paradoxically cause cardiac dysrhythmias.
While anticoagulant and antiplatelet agents do not cause syncope, they dramatically change the equation once the patient falls. Have a very low threshold for obtaining a head CT in such patients even with ground level falls.
Physical Exam
Focus your physical examination on possible injuries from a fall as well as clues to the cause of syncope. In one study of over a thousand patients with syncope, almost 30% suffered injury, while 5% had injuries characterized as “severe”.
22
C Spine.
Early in the encounter, determine the need for cervical immobilization.
Use either the NEXUS or Canadian C-spine rules (although in the Canadian rule, age of 65 or older is an indication for imaging in the context of possible cervical trauma). Elderly patients, especially those with rheumatoid arthritis or spinal diseases, are particularly susceptible to cervical spine injuries. Those with unstable fractures and patients with cervical spinal stenosis may suffer injury to the cord.
Head.
Look for signs of head trauma such as hematoma, bruising, or stigmata of basilar skull fractures. Check the teeth and jaw for signs of dental trauma or mandibular fracture and pay special attention to the tongue.
In one study, lateral tongue biting was 100% specific to grand mal seizures.
23
Biting the
tip
of the tongue is more likely associated with syncope.
24
Torso.
Chest and abdominal trauma is rare in syncope unless the patient hits their torso on the edge of a table or chair (or worse, falls down some stairs). Consider imaging if there is significant tenderness of the chest or abdomen. A large pulsatile abdominal mass deserves immediate assessment for AAA (preferably a bedside ultrasound).
Cardiac.
Pay special attention to the cardiac exam when evaluating for syncope.
Two systolic murmurs in particular should prompt an echocardiogram; the murmur of hypertrophic cardiomyopathy (HCM) (previously known as hypertrophic obstructive cardiomyopathy or HOCM) and that of aortic stenosis.
The murmur of HCM is best heard at the apex of the heart while AS is best heard over the right second interspace, lateral sternal border. Performing the Valsalva and squatting maneuvers can help distinguish between the two.
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Image courtesy of Healio Learn the Heart.
If you are unsure of your ausculatory skills, just order an echocardiogram for patients with syncope and a previously undiagnosed murmur.
Extremities.
If the patient was aware they were “going down” they may have tried to catch their
Fall On an Out-Stretched Hand
before losing consciousness; causing a
FOOSH
injury. Older patients may sustain a Colles fracture.
Check distal pulses for symmetry; as a pulse differential may be secondary to a thoracic aortic dissection.
Pelvis.
Hip fractures are one of the more common injuries in the elderly with transient loss of consciousness; carefully range each hip for signs of pain (of course, no need to range a hip when the patient has hip tenderness and shortened limb!)
Neuro.
A good neurologic exam is essential to determine if the patient had a stroke prior to the fall or suffered neurologic injury after the fall. Either way, emergent CT scan is indicated in the presence of a new deficit.
Gait.
Of all the physical exam maneuvers after a fall, getting the patient to walk is one of the most revealing. Is the patient lightheaded upon standing? Is their gait stable? Do they have pain in their hip? A simple “road test” before discharge (along with rechecking abnormal vital signs) is one of the most powerful risk management tools at our disposal.
Vital Signs
Both the American Heart Association (AHA) and European syncope guidelines claim that orthostatic vital signs are an essential part of the syncope evaluation.
2,20
The European guideline defines orthostatic hypotension as “a fall in systolic BP from baseline value ≥ 20 mmHg or diastolic BP ≥ 10 mmHg, or a decrease in systolic BP to <
90 mmHg” upon standing
.
Orthostatic blood pressure should be measured 3 minutes after standing from a supine position.
20
Measuring the blood pressure immediately upon standing is a common mistake and does not reflect orthostatic hypotension!
However, the recommendations for routine measurement of orthostatic blood pressure in syncope are not well referenced in the AHA and European guidelines. We know that a drop in systolic blood pressure of 20 points or more can occur in 11 to 50% of
asymptomatic
elderly patients.
25,26
In an excellent review of the literature, Jason Schaffer notes that the physician should consider the pretest probability of OH (orthostatic hypotension) as a cause of syncope.
26
If the patient is not having symptoms upon standing and especially if there are other probable causes for syncope, measurement of orthostatic vital signs may be misleading. In such cases a serious cardiac cause of syncope may be overlooked because of a physiologic drop in blood pressure with standing.
Conversely, if the patient has a high pretest probability of orthostatic hypotension, such as recurrent postural symptoms, especially in the face of dehydration, a negative standing test does not exclude the diagnosis. Dr. Schaffer concludes that if performed safely (with someone to catch the person if they collapse), orthostatic vital signs are acceptable for patients being admitted for syncope; however this test “should infrequently alter the decision to admit.”
Overall, routinely testing for orthostatic
symptoms
is probably more valuable than routinely testing for orthostatic
hypotension
.
Diagnostic Studies
ECG
An ECG is the single test mandated in every clinical decision rule for syncope.
It is important to remember that the ECG covers only a snapshot of cardiac activity and is not nearly as sensitive for detecting intermittent rhythm disturbances as ambulatory or ED monitoring.
Examine every ECG you read for syncope with an eye to following
6 high-risk findings
, the “Big Six”
:
- Wolff-Parkinson-White pattern (WPW)
- Prolonged QTc
- Brugada Pattern
- Hypertrophic cardiomyopathy
- Arrhythmogenic right ventricular cardiomyopathy (ARVC)
- Heart block
Wolff-Parkinson-White pattern (WPW)
Look for the delta wave and a short PR interval.
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Image courtesy of Queen’s University; Department of Emergency Medicine.
Arrow on left shows initial slurring of the QRS complex as a result of early ventricular depolarization
The arrow on the right shows the delta wave.
Prolonged QTc
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Image courtesy of Healio Learn the Heart.
Prolonged QTc may be congenital or acquired. It may lead to polymorphic ventricular tachycardia (Torsades de Pointes).
Brugada Pattern
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Image from litfl.com.
Type 1 (Coved ST segment elevation >2mm in >1 of V1-V3 followed by a negative T wave) is the Brugada sign.
Brugada Type 2 can look “STEMI”-ish in V2 or V3
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Image from litfl.com.
Hypertrophic Cardiomyopathy
Most common cause of cardiac sudden death in young adults:
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Image courtesy of Healio Learn the Heart.
Note the narrow “dagger-like” QRS complexes that touch between leads V2 and V3 (“kissing complexes”).
Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC)
Second most common cause of sudden death in young adults after HCM.
Patients will have negative T waves in V1-V3 with or without epsilon waves.
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Heart Blocks
3
rd
degree heart block demonstrates complete absence of AV conduction and requires admission, often for a pacemaker.
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Image from litfl.com.
Summary
Many conditions can cause transient loss of consciousness and the mnemonic HEAD, HEART, and VESSELS is a useful tool. Syncope comes from transiently decreased cerebral perfusion and is distinct from the syncope mimics listed above. While most causes of syncope are benign, certain types of cardiac syncope can be fatal. Remember that patients can suffer serious fall-related injury even if the cause of syncope is benign.
The patient history is often the most revealing aspect of the ED exam and should include a family history of sudden death and a review of all medications. The physical exam (especially the cardiac exam) may occasionally reveal the cause of syncope but is often more useful to detect fall-related injuries. Look for lateral tongue biting as diagnostic for seizures.
The ECG is the single most important diagnostic test for syncope and the emergency providers should instantly recognize the “Big Six” dangerous tracings.
In Part 2 of Syncope, we will look at the role of diagnostic testing in syncope and the various clinical decision rules.
References
- Day SC, Cook EF, Funkenstein H, et al. Evaluation and outcome of emergency room patients with transient loss of consciousness. Am J Med. 1982;Jul;73(1):15-23.
- Shen WK, Sheldon RS, Benditt DG, et al. 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, and the Heart Rhythm Society. Circulation. 2017;136(5):e60-e122.
- Probst MA, Kanzaria HK, Gbedemah M, et al. National trends in resource utilization associated with ED visits for syncope. Am J Emerg Med. 2015;38(8):998-1001.
- Sun BC, Emond JA, Camargo CA, Jr. Direct medical costs of syncope-related hospitalizations in the United States. Am J Cardiol. 2005;95(5):668-71.
- Huff, J. Stephen, et al. "Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with syncope." Ann Emerg Med. 007;49:431-444.
- Shen, W. K., et al. "Guideline for the evaluation and management of patients with syncope: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society." J Am Coll Cardiol 70.5 (2017): e39-e110.
- Soteriades ES, Evans JC, Larson MG, et al. Incidence and prognosis of syncope. N Engl J Med. 2002; 347:878-85.
- Thiruganasambandamoorthy, Venkatesh, et al. "Outcomes in presyncope patients: a prospective cohort study." Annals of emergency medicine 65.3 (2015): 268-276.
- Chen LY, Shen WK, Mahoney DW, et al. Prevalence of syncope in a population aged more than 45 years. Am J Med. 2006; 119:e1-e7.
- E.S. Soteriades, J.C. Evans, M.G. Larson, M.H. Chen, L. Chen, E.J. Benjamin, et al. Incidence and prognosis of syncope N Engl J Med, 347 (2002), pp. 878-885
- Sun BC, Emond JA, Camargo CA, Jr. Characteristics and admission patterns of patients presenting with syncope to U.S. emergency departments, 1992-2000. Acad Emerg Med. 2004; 11:1029-34.
- Kapoor WN. Evaluation of syncope in the elderly. JAm Geriatr Soc 1987;35:826–8.
- Coleman, Diana K., Brit Long, and Alex Koyfman. "Clinical Mimics: An Emergency Medicine–Focused Review of Syncope Mimics." The Journal of emergency medicine 54.1 (2018): 81-89.
- Chen, Min, et al. "Value of witness observations in the differential diagnosis of transient loss of consciousness." Neurology (2019): 10-1212.
- Brigo, Francesco, et al. "The diagnostic value of urinary incontinence in the differential diagnosis of seizures." Seizure 22.2 (2013): 85-90.
- Hoefnagels, W. A. J., et al. "Transient loss of consciousness: the value of the history for distinguishing seizure from syncope." Journal of neurology 238.1 (1991): 39-43.
- Long, Brit, and Alex Koyfman. "Vascular causes of Syncope: an emergency medicine review." The Journal of emergency medicine 53.3 (2017): 322-332.
- Chang, Anna Marie, et al. "Recurrent syncope is not an independent risk predictor for future syncopal events or adverse outcomes." The American journal of emergency medicine (2018).
- Gibson, Thomas A., Robert E. Weiss, and Benjamin C. Sun. "Predictors of short-term outcomes after syncope: a systematic review and meta-analysis." Western Journal of Emergency Medicine 19.3 (2018): 517.
- Brignole, Michele, et al. "2018 ESC Guidelines for the diagnosis and management of syncope." European heart journal 39.21 (2018): 1883-1948.
- Morales, Ana, et al. "Family history: an essential tool for cardiovascular genetic medicine." Congestive heart failure 14.1 (2008): 37-45.
- Bartoletti, Angelo, et al. "Physical injuries caused by a transient loss of consciousness: main clinical characteristics of patients and diagnostic contribution of carotid sinus massage." European heart journal 29.5 (2007): 618-624.
- Benbadis, Selim R., et al. "Value of tongue biting in the diagnosis of seizures." Archives of Internal Medicine 155.21 (1995): 2346-2349.
- Brigo, Francesco, Raffaele Nardone, and Luigi Giuseppe Bongiovanni. "Value of tongue biting in the differential diagnosis between epileptic seizures and syncope." Seizure 21.8 (2012): 568-572.
- Ooi, Wee Lock, et al. "Patterns of orthostatic blood pressure change and their clinical correlates in a frail, elderly population." Jama 277.16 (1997): 1299-1304.
- Aronow, Wilbert S., et al. "Prevalence of postural hypotension in elderly patients in a long-term health care facility." The American journal of cardiology 62.4 (1988): 336.
- Schaffer, Jason T., et al. "Do Orthostatic Vital Signs Have Utility in the Evaluation of Syncope?" The Journal of emergency medicine 55.6 (2018): 780-787.
Images
- Distinguishing the murmur of HOCM and aortic stenosis: https://www.healio.com/cardiology/learn-the-heart/cardiology-review/topic-reviews/hypertrophic-obstructive-cardiomyopathy-hocm
- Wolff-Parkinson-White Pattern (WPW): Queen’s University; Department of Emergency Medicine. https://meds.queensu.ca/central/assets/modules/ts-ecg/wolffparkinsonwhite_syndrome.html.
- Prolonged QTc: https://www.healio.com/cardiology/learn-the-heart/ecg-review/ecg-topic-reviews-and-criteria/prolonged-qt-interval-review.
- Brugada Pattern: https://lifeinthefastlane.com/what-is-brugada-syndrome/.
- Brugada Type 2: https://lifeinthefastlane.com/what-is-brugada-syndrome/
- Hypertrophic Cardiomyopathy: https://www.healio.com/cardiology/learn-the-heart/ecg-review/ecg-archive/hypertrophic-obstructive-cardiomyopathy-hocm-ecg-example-2.
- Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC) https://litfl.com/arrhythmogenic-right-ventricular-cardiomyopathy-arvc/.
- Epsilon wave in V1: https://litfl.com/arrhythmogenic-right-ventricular-cardiomyopathy-arvc/
- Prolonged S wave: https://litfl.com/arrhythmogenic-right-ventricular-cardiomyopathy-arvc/
- 3rd degree heart block: https://litfl.com/av-block-3rd-degree-complete-heart-block/.
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2019 Annual Meeting
The EPIX Annual Meeting this yer will be held in September in Orlando, Florida!
We look forward to gathering with our insured emergency and urgent care medicine groups
and prospects
for an opportunity to network and share resources. As always, we will be providing excellent CME education.
If you would like more information on the meeting, please contact Danielle Barclay at info@epixrrg.com or 916-772-2094.
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Copyright © 2019 Emergency Physicians Insurance Exchange RRG. The information in this alert should be modified based on individual patient circumstances, physician judgment and local resources. These alerts are provided for educational purposes and are not intended to establish guidelines or standards of care. They are not intended to be followed in all cases and do not provide any medical or legal advice. EPIX Patient Safety Briefs are filed on the EPIX website in the Resource Center under Email Alerts.
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