Passed out…Peace out. Who can go home after syncope?

Discussing: Quinn et al. Annals of Emergency Medicine. Prospective Validation of the San Francisco Syncope Rule to Predict Patients With Serious Outcomes

Main Points:
1. This 2006 prospective cohort trial aimed to validate a clinical rule to help risk stratify patients presenting to the ER with syncope in relation to short term outcomes. The rule was validated to have a sensitivity of 98% in preventing serious outcomes after syncope within 30 days.

2. The San Francisco Syncope rule is positive if the patient has a chief complaint of “shortness of breath”, a medical history of CHF, a presenting SBP <90mm Hg, a hematocrit <30%, or an abnormal ECG result (any non-sinus rhythm or new changes).

Background:

Approximately 25% of the general population will have an episode of syncope in their lifetime. Patients with syncope account for 1-2% of all Emergency Department visits and hospital admissions. Patients admitted for syncope, however, have been shown to receive little to no further diagnostic care, nor do they often receive a firm diagnosis concerning the cause of their syncope. Given this, the authors’ purpose was to validate the decision rule in a prospective cohort of consecutive ED patients by determining whether it can predict short-term serious outcomes.

Syncope was defined as “transient loss of consciousness with return to baseline neurologic function,” and patients presenting with acute syncope or pre-syncope were screened for the study. When a clinician had finished working up the selected patient, a short Web-based questionnaire was completed to evaluate for aspects of the history, ECG, vitals or lab results that pertain to the decision rule. In this trial, the decision rule was 98% sensitive and 56% specific to predict a serious outcome within 30 days. If applied in the study cohort, this clinical rule may have decreased syncope admissions by 24%.

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Clinical Image of the Week: Case 1

This is a case I saw in the ED. This case has been deliberately altered to protect the identity of the patient:

28 y/o patient presents to the ED after sustaining blunt trauma to the chest. An EKG is ordered as part of her workup:

Case 1 Upon further questioning, the patient endorses periods of palpitations over the past couple of months where her “heart was racing”. She denies chest pain, shortness of breath, dizziness, or syncope with these episodes.  What’s the diagnosis?

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