SYNCOPE a symptom not a diagnosis Clinical cases

SYNCOPE a symptom, not a diagnosis… Clinical cases Dr Jaycen Cruickshank Ballarat Emergency Education Updated June 2012 1

Learning objectives they need to be your objectives… l l l To apply your knowledge and the information presented in our syncope presentation to these cases To make a diagnosis and safe management plan for each case For ACEM trainees To consider how these cases might appear and be answered in the FACEM exams To write and complete practice questions To realize that good answers in exams are often good answers when in charge of the ED.

Case 1 l l 32 yo male, Intravenous drug user Presents with frequent syncopal episodes and ? Seizure activity Medication – methadone PMHx – nil else significant Updated June 2012 3

Case 1 ECG Updated June 2012 4

Case 1 ECG What would you do if this then happened? Updated June 2012 5

Reminder causes of QT prolongation l l l l Hypomagnesiuaemia Hypokalamia Hypocalcaemia Na Channel blockers – type 1 a, TCA Raised ICP Altered conscious state Hereditary l l Lange Nielsen – QT prolongation and deafness Romano Ward - QT only Hypothermia Drugs Updated June 2012 6

Clinical Case 2 l l l l 19 year old university student Wakes up Sunday morning to the sound of his mobile phone Gets up out of bed, talks for half a minute, then feels funny and blacks out Housemate hears phone and the fall, and runs into the room, he is coming around quickly Referred by GP for ED assessment ECG normal Further assessment and management? Updated June 2012 7

Case 3 middle aged man with fainting episode l l l ED doctor presents to the ED physician… Middle aged man with syncope No features to suggest seizure Full assessment and no obvious cause Is there any role for a troponin now and eight hours, how long should we observe for?

Case 3 cont. l l l History of presenting complaint. He drove 8 hours Walked into house Went to make cup of tea Then syncopal episode Rapid recovery to normal… he heard wife calling the ambulance l l l Background Truck driver Working 2 jobs Very little sleep Past history similar episode Investigation EEG and echo and stress test normal

Case 39 year old l 39 yo syncopal episode No prodrome No pmhx Normal physical examination l Ddx? l l l Updated June 2012 10

ECG Updated June 2012 11

ECG brugada Updated June 2012 12

BRUGADA SYNDROME POLYMORPHIC VT 1/3 will develop 2 nd episode in 2 years Updated June 2012 13

Case 4 16 year old l l l 16 year old with syncope whilst playing basketball at school No prodromal symptoms Awoke after a few seconds No PMHx No FHx Updated June 2012 14

16 year old, syncope while playing basketball Interpret this ECG. Updated June 2012 15

HYPERTROPHIC OBSTRUCTIVE CARDIOMYOPATHY WALL THICKNESS PREDICTOR OF DEATH SUBGROUP WILL NEED AN ICD Updated June 2012 16

Clinical case 5 l l 25 year old with syncope during a lecture No chest pain, no dyspnea No PMHx FHx – father died suddenly aged 60 Updated June 2012 17

Further history l l l Further history Syncope while seated May indicate arrhythmia Need more details on what lecture was about, the family history Needs ECG AA Arrhythmia, brugada, CMP Updated June 2012 18

Case 5 cont. What is your diagnosis? Updated June 2012 19

Case 5 cont. WPW Updated June 2012 20

Clinical case 6 l l l 68 yo presents following syncopal event following going to the bathroom at 4 am Situational Micturition/defecation syncope What if fainted before going to toilet? How does that change things? Updated June 2012 21

Clinical Case 6 l l 45 year old man collapses and takes 6 or 7 minutes to wake up and then he is a little confused Diagnosis? Probably a seizure What further history and examination would be relevant? Updated June 2012 22

Clinical case 7 courtesy emcore. com l l A 52 year old man is brought to the ED following a collapse. He had been sitting at the kitchen table reading the paper and the next thing he knew he was on the floor He woke with a vice like headache and pins and needles down the left arm He is in AF Updated June 2012 23

Clinical Case 7 further history l l The patient had a biopsy of his ear where there was carcinoma detected He had just got home following a CT of his neck, looking for lymph node enlargement He had the CT with him and had asked people to look at the report, but no one would tell him what it meant His brother died three months earlier from cancer Updated June 2012 24

Clinical case 7 l l l He was sitting at the kitchen table thinking about dying from cancer and getting very anxious. He got hot and sweaty, felt a little dizzy and collapsed When he awoke, he did have a vice like headache and pins and needles down left arm. He was in AF He was seeing his cardiologist for AF, which was controlled and he was on aspirin Two previous episodes Previously investigated CT/LP normal, diagnosis migraines was made. Updated June 2012 25

Summary l l l History, exam, ECG Cardiac vs non cardiac Admit for no diagnosis and high risk Older/abnormal ECG, cardiac history including CCF Don’t forget to look for other causes E. g TIA, dissection.