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The Primary Exam
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This is one of my favourite areas, as patients present very frequently with this symptom. That very fact makes syncope a challenge. It is a symptom, not a condition in itself. We have to find the cause of the syncope. We need to be experts in this area as syncope presents some 5% of all emergency department visits and comprises 6-10% of admissions. Our role is to risk stratify patients and make sure we don’t send home those with potential sinister causes. This is not as easy as it sounds, as there are many causes. I often hear, “… well he’s still a little hypotensive, so that was probably the cause…..” What was probably the cause? Up to 50% of patients with syncope from whatever cause will be hypotensive. Also beware hypotension in the elderly. In this age group you need to start thinking about the abdominal aortic aneurysm. Did you know that up to 12% of patients with thoracic aortic dissection, present with syncope as their ONLY complaint? That is a little scary. We need to differentiate those causes associated with mortality and morbidity. This means working out who has had a cardiac or neurological cause of syncope as well as differentiate syncope from seizure.

WHY IS FINDING CARDIAC CAUSES SO IMPORTANT?  Because mortality from missed cardiac causes can reach 30%.  Because underlying heart disease, irrespective of the cause of the syncope, is associated with an increased risk of death.

WHAT ABOUT THE NEUROLOGICAL CAUSES?  We know that patients with a neurological cause of syncope have two times the risk of a stroke, when compared to those without syncope. TAKING A GOOD HISTORY IS THE KEY  How did the episode occur? Was there a sudden loss of consciousness, or was there a prodrome of sweating and dizziness etc? This is important as a sudden loss of consciousness with no prodrome leads us to a cardiac cause. Was it associated with a change in position or did it occur whilst sitting? Again, syncope when sitting or lying can potentially point to a more sinister cause, which includes cardiac or neurological. -Is there a family history or cardiac disease or sudden cardiac death? Here we need to start talking about BRUGADA SYNDROME and thinking about those terminating arrhythmias that can occur. -Were there other associated symptoms of chest pain, or palpitations, or vertigo or nausea and vomiting? -Was there a headache and if so was it sudden? -Let’s not miss the potential subarachnoid haemorrhage. This is such an important topic. Watch the video which contains parts of a previous lecture I’ve given on this and know that the latest will be covered tis year in the lecture series.

The update at RESUS 2010 will include:
An approach to the diagnosis of Syncope -Syndromes such as BRUGADA, that you must learn about and cannot miss.
A discussion of the rules in use for looking at patients with syncope, such as the San Francisco Syncope Rule and the Boston Syncope Rule.
We’ll talk about loop recorders, and here’s a really important thing I can’t understand. Some of these loop recorders are there to catch an arrhythmia, yet for them to be activated, the patient has to hold a probe up to them when they feel a syncopal episode coming on. What?! I have never had a patient successfully do that.
We’ll talk about tilt table testing.
We’ll also talk about some of the latest treatments and MORE!

For now enjoy the snippets of video I’ve put together on the ‘resus blog’ and I hope you’ll take the time to come and listen to some great lectures at RESUS 2010

Dr Peter Kas

Emergency Physician, Educator. Key Interests: Resuscitation, Airway, Emergency Cardiology, Clinical Examination. Creator resus.com.au.

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