syncope and near syncope are one of the most common presentations to the ED and need to be differentiated from a primary seizure event (seizure activity may be secondary to the syncopal event if there is prolonged reduced blood supply to the brain)
in the elderly they are particularly concerning, not only because of the higher incidence of potentially life threatening causes but also in the high morbidity and mortality associated with falls such as fracture neck of femur (#NOF), head injury in the adult patient, fractured ribs, etc, not to mention the significant subsequent loss of confidence walking.
while many are due to benign conditions (especially in the younger population) such as vasovagal events and cough/micturition syncope there are a wide range of not so benign conditions that need to be considered including:
persistent decreased cognitive function following the collapse suggests:
ongoing hypotension
hypoglycaemia
post-ictal state - this should resolve over an hour or so
drug overdose
mechanical intracranial event such as subarachnoid haemorrhage (SAH), stroke (CVA), other types of intracranial haemorrhage such as subdural, although these tend not to have a sudden syncopal event but gradual deterioration
decreased cognition with cerebellar signs (may initially be subtle), vertigo or occipital blindness should suggest a posterior circulation stroke
infective intracranial event such as meningitis, although, again, these tend not to have a sudden syncopal event but gradual deterioration
syncope and falls in the elderly
an ever increasing problem compounded by increasing number of elderly population and overzealous Rx of hypertension
elderly usually do not have recall of a syncopal event causing a fall
vasovagal syncope / neurocardiogenic syncope becomes a much more uncommon cause of syncope as age increases above 35 yrs age and thus the elderly require a low suspicion for other cardiac or neurologic causes, in particular:
if an elderly patient requires admission for the episode of syncope:
if clinical features of PE (eg. RR > 20, BP < 110, HR > 100), known active cancer, or probable or PH DVT then test for PE
note that patients with alternative causes for syncope still had a 12% probability of having a PE causing the syncope and their PEs they tend to be more proximal and life-threatening
if no clinical features PE/DVT/active cancer, then probability of “occult PE” is around 5% and if you believe the mortality benefit of anticoagulation is 3.2% or more which is probably the case, then we should consider testing with D-Dimer
Carotid sinus massage should be considered in both supine and upright positions whilst cardac monitored as patients with this cause develop 5-10 secs of asystole with often delayed return of BP. These patients do well with cardiac pacemaker.
pre-excitation syndromes including WPW - PR < 120msec, Delta wave causing wide QRS with discordant ST-T change, +/- negative Delta wave causing “pseudo-Q wave”, or a prominent R wave in V1-3 which can mimic posterior AMI
Brugada syndrome - RBBB (maybe incomplete), ST elevation in R V1-3 leads - may be coved or saddle-back morphology
history, medication history (is the patient on anticoagulants, etc), and examination (is there evidence of acute stroke?) to ascertain potential cause and exclude any injuries due to a fall
targeted investigation which should also include:
blood sugar level
vital signs - is the patient hypotense or septic?
12 lead ECG
look for evidence of heart block or sick sinus syndrome
cardiac conditions outlined under the paediatric causes above - as these may present in adult life
cardiac monitor whilst in ED
baseline bloods:
FBE, U&E
consider troponin, Ca,Mg,PO4 if possible primary cardiac arrhythmia
HCG if woman of child bearing age
Group and Hold if possible acute blood loss
blood cultures, serum lactate, LFTs, lipase, CRP, CXR, urinalysis, etc if sepsis is likely
urgent CT brain if ongoing decreased cognition, meningism, focal neurology or sudden onset headache
urgent FAST USS for intrabdominal bleeding, and also assessment of possible abdominal aortic aneurysm (AAA) if hypotension or abdominal pain are features
consider admission for 12-24hrs of cardiac monitoring if possible primary cardiac arrhythmia
eg. elderly with syncope whilst sitting and no cause found