Syncope MDM

This patient had the classic characteristics of syncope (1) transient LOC, (2) loss of postural tone and (3) full & immediate spontaneous recovery. There is nothing in the history or physical to suggest common syncope mimics: ***seizure, ***posterior circulation stroke, ***hypoglycemia, ***hypoxemia, ***heat stroke or ***head trauma. My suspicion for ***AAA, ***PE, ***MI, ***GIB, ***ectopic pregnancy, ***SAH and ***arrhythmia/persistent bradycardia is low. This patient doesn’t have a history of ***recurrent syncope to suggest structural heart disease.

HIGH RISK FEATURES:
  • ***no new onset chest pain, SOB or headache
  • ***no exercise induced (AVRC, Brugada, HCM)
  • ***no sudden onset palpitations
  • ***no syncope in supine or sitting position
  • ***no lack of prodromal symptoms
  • ***no family history of sudden death at a young age
  • ***no history of structural heart disease, CHF, CAD, cardiac murmur or ↓ EF
  • ***no recurrent syncope
  • ***no hypotension, GIB, persistent bradycardia or new systolic murmur
WORKUP:
  • ***no signs of trauma
  • glucose: ***
  • troponin: ***not indicated
  • d-dimer: ***not indicated
  • pregnancy: ***not pregnant
  • echo: ***if suspect structural heart disease (obs pt to get it)
  • EKG:
    • ***normal PR (no WPW seen)
    • ***no high degree AV blocks (Mobitz 2 or 3rd degree block)
    • ***normal QTc
    • ***no ischemic patterns
    • ***no dysthymia seen
    • ***no Brugada pattern
    • ***no ARVC (no epsilon wave, and in V1-V3 no TWI/no S-upstroke > 55ms/no QRS widening & no episodes of v-tach/freq PVCs)
CANADIAN SYNCOPE RULES:
  • ***Predisposition to vasovagal symptoms (Triggered by being in a warm crowded place, prolonged standing, fear, emotion, or pain) (-1)
  • ***Heart disease history (CAD, atrial fibrillation or flutter, CHF, valvular disease) (+1)
  • ***sBP <90 or >180 mmHg on any reading (+2)
  • ***Elevated troponin (+2)
  • ***Abnormal QRS axis (+1)
  • ***QRS duration >130 ms (+1)
  • ***Corrected QT interval >480 ms (+2)
  • ***ED Diagnosis: Cardiac (+2), Vasovagal (-2), Uncertain (0)
CSR SCORING:
  • Score = -3: Very low risk (0.4%)
  • Score = -2: Very low risk (0.7%)
  • Score = -1: Low risk (1.2%)
  • Score = 0: Low risk (1.9%)
  • Score = 1: Medium risk (3.1%)
  • Score = 2: Medium risk (5.1%)
  • Score = 3: Medium risk (8.1%)
  • Score = 4: High risk (12.9%)
  • Score = 5: High risk (19.7%)
  • Score = 6: Very high risk (28.9%)
  • Score = 7: Very high risk (40.3%)
  • Score = 8: Very high risk (52.8%)
  • Score = 9: Very high risk (65.0%)
  • Score = 10: Very high risk (75.5%)
  • Score = 11: Very high risk (83.6%)

Reference