Syncope, Questions

Syncope1. In which patients presenting with syncope do you get a Non-Contrast Head CT (NCHCT)?

2. In which patients presenting with syncope do you get a troponin?

3. Do you get orthostatic vital sign measurements in patients presenting with syncope? How do you use them?

4. Do you manage patients presenting with near-syncope differently than those presenting with syncope?

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7 Responses to Syncope, Questions

  1. Mike says:

    Honestly the questions are a bit disappointing for EM lyseum. You have skirted the tough issues. For example “How do you dispo that 50 year old with bona fida syncopy who has no heart disease and all tests negative?”. “What is the true yield of 23 hour obs/full admission for syncopy patients?”

    • emlyceum says:

      Mike – sorry to disappoint you on these questions. The first question you ask has little answers in the literature to go off of and we try to ask questions where there is literature to formulate an “answer.” Agree that it’s a critical question to ask. There is probably a bit more info on the second question you ask (what I’ve seen says no utility). Something for us to add in the future. If you have any literature you’ve seen on either that you want to pass along, we’ll add these questions into our queue. Thanks!

    • Tim Horeczko says:

      Agree that EM Lyceum has been hard-hitting and informative — most likely these questions are the starting platform for a more in-depth discussion. It’s amazing how pervasive misconceptions of syncope are (and there are recent articles touching just on the above). Have faith, my friend! I’m sure the team at EM Lyceum will come through.

  2. Joel Herrington says:

    > 1. In which patients presenting with syncope do you get a Non-Contrast Head CT (NCHCT)? > > –>generally only those in whom I am worried about clinically significant head trauma resulting from the syncopal event or in those who I am worried about a spontaneous bleed (ex SAH) as the cause of their syncope > > 2. In which patients presenting with syncope do you get a troponin? > > –>those with older age, hx of severe CHF, those with symptoms concerning for ACS /PE prior to passing out > > 3. Do you get orthostatic vital sign measurements in patients presenting with syncope? How do you use them? > > –>yes, I get these for our internal medicine colleagues where I work. > > 4. Do you manage patients presenting with near-syncope differently than those presenting with syncope? > > –>I do not manage them differently however they are viewed entirely differently by the hospitalist colleagues where I work. >

    >

  3. 1. In which patients presenting with syncope do you get a Non-Contrast Head CT (NCHCT)?
    Only those with a known brain structural lesion. Otherwise, the only time I’d get a Head CT is if they fall under a different diagnostic pathway (head trauma or stroke). Head CT for syncope as a lone diagnosis (normal neuro exam) is extremely low yield.

    2. In which patients presenting with syncope do you get a troponin?
    Only the patients you have already decided to admit (which will include those with ECG changes). The negative predictive value of a troponin isn’t sufficient to rule out a future adverse event. A better question is regarding the use of BNP, which I think has more utility.

    3. Do you get orthostatic vital sign measurements in patients presenting with syncope? How do you use them?
    No.

    4. Do you manage patients presenting with near-syncope differently than those presenting with syncope?
    No. The best literature on the topic was just published in Annals and shows that the rate of serious events after near syncope is only slightly lower than the event rate for syncope, so I would not use the lack of loss of consciousness as a way to risk stratify a patient into a lower risk group.

  4. emlyceum says:

    Thanks everyone for the great thoughts/answers. Although there’s considerable literature on this topic, we felt it important to address because we see so much practice variability. We’re excited to share our answers with everyone later in the month!

  5. 1. In which patients presenting with syncope do you get a Non-Contrast Head CT (NCHCT)?
    -trauma or prodromal HA / neck pain causing syncopal event. prolonged (or failure to) return to baseline mental status.

    2. In which patients presenting with syncope do you get a troponin?
    – In general I send trops on most if not all syncopal patients I draw labs on. With that said, I tend to only draw labs on those I plan on obs/admit, and I realize trop’s never seem to change my “admit to tele” disposition. The dogma of trops going hand in hand with cardiac monitoring is going to be a tough one to break. I’m not certain we’ll ever see it universally.

    3. Do you get orthostatic vital sign measurements in patients presenting with syncope? How do you use them?
    -generally not, unless specifically asked by inpatient team or obs.

    4. Do you manage patients presenting with near-syncope differently than those presenting with syncope?
    -same, usually if SF Syncope neg, I’ll suggest dc but offer obs.

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