Cardinal Presentations
This post is part of a series called “Cardinal Presentations”, based on Rosen’s Emergency Medicine (8th edition).
Causes of Syncope
History
- Rate of onset
- Position at onset
- Duration, rate of recovery
-
Preceding features
- Obstruction: associated with exertion
- Neurocardiogenic: associated with emotion, micturition, bowel movement, emesis, neck movement
-
Following features
- Seizure: Postictal confusion
- Hypotension: Initial VS
- Associated trauma
Physical Examination
- VS: rhythm, BP, temperature
- HEENT: mucous membranes (laceration, dry), trauma, papilledema
- CV: murmur (AS), rub (pericarditis), bruit (cerebrovascular disease), JVD (obstruction)
- Lungs: crackles (CHF)
- Abdomen: pulsatile mass (AAA)
- Extremities: pulse discrepancy (dissection)
- Neuro: focal findings (stroke, mass, seizure)
Evaluation
- ECG: arrhythmia (PR, QT, Brugada, unanticipated hypertrophy, RV strain, pericarditis)
- Orthostatic VS
- CBC: anemia
- BMP: electrolyte abnormalities (hyponatremia, hyper/hypokalemia)
- Glucose: hypoglycemia
- Troponin: ischemia
- B-hCG: ectopic
- Utox: drugs
- CXR: dissection
- CT head: focal neurological findings
- CT PA: concern for PE
- US abdomen: AAA
San Francisco Syncope Rules (CHESS)
- CHF
- Hematocrit <30%
- ECG abnormality
- SBP <90mmHg
- SOB
References
- De Lorenzo, R. (2013). Syncope. In Rosen’s Emergency Medicine – Concepts and Clinical Practice (8th ed., Vol. 1, pp. 135-141). Elsevier Health Sciences.