Emergency Medicine Forum

A spry 68 y/o female presents after syncope.  She is with her sister. The history is peppered with comments about their last cruise.  They just arrived back today, and at the airport, she had a brief episode of syncope.  She was waiting for the luggage when she described feeling very dizzy, lightheaded, and then she sat down.  Her sister said she was unconscious for only about 15 seconds.  There was no seizure activity. The security responded, but they declined any medical assistance at the airport, and just decided to come directly to the ED here as it was close to their home.

Past Medical History:  History of mild hypertension.  The patient noted she just stopped eating any salt, and then didn’t need any medication.  Last blood pressure check in the pharmacy was “OK” (approximately one year ago).  She hasn’t seen a doctor for years and isn’t sure if her previous doctor is still in practice.  (“I avoid doctors…that’s why I’m still here!” she adds with a smile.)
Past Surgical History:  She had a hysterectomy ‘years ago’. 
Medications:  None
Allergies None
Social history:  They were both retired school teachers, neither was ever married. “We just have each other”.   No smoking but they do have some wine with dinner occasionally.  They just got back from a cruise in the Caribbean, and flew directly from Miami to Detroit (2.5 hours) just before the syncope episode. 
ROS: No fevers, no chills, no cough, no pain anywhere (including no chest pain).  No shortness of breath, no abdominal complaints, she had a normal BM three days ago, but she usually goes every day (traveling “always binds me” so mild constipation was not unusual).  She was slightly nauseous with the episode, but no vomiting.   She did get ‘clammy’ per her sister, but that has resolved.  No unusual exposures while on the cruise (“We mostly shop.”)
PE:  Well developed female in no acute distress.
BP:   100/60, RR=20, HR=100, Temp=98F, Sat=98
HEENT:  Unremarkable
HEART:  RRR, systolic murmur present (3/6) New per patient:  “That’s news to me, but I haven’t been checked in a while!”
LUNGS:  Clear bilaterally
ABD:  Slightly obese, no tenderness, no masses. No palpable AAA. BS present.
EXT:  No rashes.  No palpable cords or edema to legs.
NEUROLOGIC:  Non-focal

1. What is the differential?

The differential is quite long in this case.  I like to use a pneumonic (especially useful at night when you are tired and may not remember all the potential life threats for any given complaint).
It is TINVANMANTIC  (rhymes with romantic!)
 
Trauma
 Infection
 Neoplasm
 Vascular
 Anatomic (this is so you don’t forget glaucoma in headache patients, etc.)
 Neurologic
 Metabolic
 Auto-immune/Endocrine
 Nutritional
 Toxic
Iatrogenic/Idiopathic
 Congenital

So for this patient:

Trauma:  No history of trauma.
Infection:  She did just travel, but no vomiting, diarrhea, fever, cough dysuria.  Infection shouldn’t cause syncope, unless the patient is hypotenisve, too.
Neoplasm:  Possible, but unlikely the cause of syncope
Vascular:  Lots of stuff  here: Consider AAA, GIB.  SAH (sub arachnoid hemorrhage around brain) can cause it,  but unlikely based on history (no headache).  Cardiac arrhythmia possible.   PE  possible, but plane ride only 2 ½ hours, and no hypoxemia, but slight tachycardia  present. 
Anatomic:  Anything anatomic related causing the syncope?  Sudden increased  intracranial pressure from acute hydrocephalous (from colloid cyst of the 3rd  ventricle) can cause this, but no headache present in this patient.  Acute  pericardial tamponade can do it, but it wouldn’t quickly resolve.
Neurologic:  See above . . .doubt any neuro cause based on history. Always  possibility of atypical seizure, but doubtful based on history.
Metabolic:  Hypoglycemia can cause syncope, but no hx of diabetes, and blood glucose  at triage = 138.  Other electrolytes can cause arrhythmias, leading to syncope, but  no history to suggest this.
Autoimmune/Endocrine: Doubtful based on history.
Nutritional:  They are both well nourished, I doubt any deficiencies.   
Toxic:  No unusual exposure.
Iatrogenic/Idiopathic: Nothing to suggest this.
Congenital:  Doubtful in a 68 y/o.

2. What do you need to do?  What tests to order?

The first thing is to finish the physical exam…

Rectal exam necessary to look for GI bleeding (GIB).  Quick ultrasound can also evaluate for the possibility of Abdominal Aortic Aneurysm (AAA).  Ultrasound normal, but rectal did reveal melena.

My approach for a GIB is fairly routine, although this case was not.

My usual GIB orders: IV x 2 (…I always want a backup IV in any GIB), oxygen, telemetry, vital signs q 10 min till stable, blood work (CBC, Lytes, BUN, Cr, GLU, Type and Cross x2 (hold)), NG tube to low suction, Acute abdominal X-ray series (not that it was going to help me, but with a significant GIB, surgery will be involved and want it), and EKG in older patients (because of the syncope, and because anemia/GIB can cause ischemia).

Pepcid IV was also ordered.

3. What is the San Francisco Syncope rule?

This ‘rule’ uses five criteria to help predict who needs to be admitted.  The mnemonic CHESS can help you remember them:  (presence of any one would suggest need for admission)

a.  Congestive heart failure history
b.  Hematocrit < 30% 
c.  ECG abnormal (non-sinus rhythm, or new changes compared with old ECG.
d.  Shortness of breath
e.  Systolic blood pressure < 90 mm Hg at triage.

Using this rule one initial prospective validation study revealed a sensitivity of 98% and a specificity of 56% (1).

Another study evaluated risk factors for death after ED visits for syncope, and found the above risk factors, PLUS age >65 were predictive of death at six months (death rate of 3.8%). (2).

However, several recent studies have questioned its sensitivity.  One study found it may not be directly applicable in the elderly population (sensitivity in patients age 65 and older was only 76%) (3).  And two other studies found that external validation revealed lower sensitivity than the original validation study (89% in one, and 74% in the other). (4,5).

Another recent study (published this month) found these variables to be predictive of a cardiac cause of syncope: (6)

Abnormal ECG and or heart disease
Palpations before syncope
Syncope during effort or in supine position
Absence of autonomic prodrome
Absence of predisposing and /or precipitation factors. 

So while the San Francisco Syncope rule is a great starting point, it should be used with caution, especially in the elderly, as it may not be as sensitive as originally thought. 

4. She begins to vomit bright red blood.  What will save her life now?

Once active UGI bleeding is identified, the patient needs a stat endoscope to stop the bleeding.  She also needs blood now.  But, while I can pour blood into her, the real answer is to stop the bleeding.  Scoping her is necessary, and a stat call to surgery and GI was made.  (At our institution, both get involved in these unstable GIB patients).  THE SICU resident was also called.

Case Outcome: 

As soon as my physical was done, I knew the cause of the syncope, and told the sisters that she needed to be admitted. 

While all of these orders were underway, I began managing a patient in our critical care area.  I was called back to her bedside (about 30 min later) when the nurse called me and told me she had dropped her blood pressure and vomited bright red blood.

My approach is to do a quick repeat H and P on any patient with a change in condition.

At this time, she looked sick. She was becoming lethargic (less chatty, answering questions with only simple one word answers). One attempt at NG had resulted in the vomiting of about 300 cc of bright red blood and a drop in her blood pressure, she was refusing further attempts. (“I need a break”).  Her blood pressure had dropped to 85 systolic, and her heart rate was up to 120.  Her SAT had dropped to 89% on two liters oxygen.  She had her x-rays already done, and two IV’s were in place.  The blood had been sent and was getting processed.  The nurse had initiated a NS bolus after the blood pressure began to drop, and she was in trendelenburg position. 

She had been placed on 100% NB and SATS increased to 95%. She was complaining of left shoulder pain and shortness of breath. 

Repeat exam now revealed:
Airway open, gag present (she just threw up after the NG attempt)
Lungs = BS bilaterally, rales 1/2 the way up. 
Heart: Loud holosystolic murmur (now 4/6)—increased from admission
Abd soft, non-tender except in the epigastric area, where she now has some tenderness.
Ext:  Unremarkable
Neuro:  Will answer simple questions, follows simple commands.

A repeat EKG was ordered, repeat CXR, and blood was asked to be sent up (Type O if type specific not available).  A central line was initiated to improve fluid/blood resuscitation access, and get a CVP reading.  The repeat EKG revealed a STEMI.  It turns out they never did the first EKG that was ordered, so it was unclear if these changes had evolved since her arrival (originally she had no pain, but after vomiting blood and dropping her pressure, she began to complain of left shoulder pain).  (The nurse was initially busy with the patients IV/blood work, then x-ray came, then the NG attempt was made, then she became hypotensive—so they never had a chance to get the EKG done—not an excuse…just an explanation.).  A Venous blood gas and lactate were ordered, along with coagulation profile (I usually don’t routinely order PT/PTT/INR unless the patient is sick, or unless there is a history of signs on physical exam to suggest liver disease or coagulapathy—in this patient it was added as the patient was now very sick). 

I also called cardiology stat and activated the cath lab. 

I had asked the sister to step out when I arrived (shortly after she began to vomit a large amount of bloody emesis). Shortly after the central line had been placed, she became more hypotensive, and required intubation.  Within five minutes of intubation she coded and we were unable to resuscitate her (equal BS after central line and after intubation—no evidence for pneumothorax), although we worked on her for quite some time.

In hindsight, the EKG should have been done sooner, but it may not have shown the STEMI, or it may have.   As she coded so quickly into the ED course, even if the cath lab had been activated sooner, I’m not sure it would have saved her (she coded about 40 minutes into the ED course).  I suspect she developed the GI bleed, was hypotensive at the airport which started the coagulation cascade of a coronary artery high grade blockage, which then clotted off with the second episode of hypotension. (She never had any pain until she vomited the blood, then she had left shoulder pain.)

It always disturbs me to have a patient arrive talking, and then die in the emergency department.  This patient even more so as she had such a kind demeanor.   Both she and her sister were very sweet, and I still remember them even though it’s been a few years.  It’s odd the way you never forget some patients, even though you only cared for them for a short while.  I wonder if our patients remember us in the same way……

References:
1)  Quinn J, McDermitt D, Stiell I, Kohn M, Wells G.  Prospective Validation of the San Francisco Syncope Rule to Predict Patients with Serious Outcomes. Ann Emerg Med 2006 May;47():448-54.  Accessed at: “http://www.ncbi.nlm.nih.gov/pubmed/16631985?ordinalpos=9&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum”

2)  Quinn J, McDermott D, Kramer N, Yeh C, Kohn MA, Stiell I, Wells G.  Death After Emergency Department Visits for Syncope:  How Common and Can it be Predicted?  Ann Emerg Med 2008 May;51(5):585-90. Accessed at:  “http://www.ncbi.nlm.nih.gov/pubmed/17889403?ordinalpos=3&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum”

3)  Schladenhaufen R, Feilinger S, Pollack M, Benenson R, Kusmiesz AL.  Application of San Francisco Syncope Rule in Elderly ED Patients.  AM J Emerg Med 2008 Sep;26 (7):773-8.  Accessed at: “http://www.ncbi.nlm.nih.gov/pubmed/18774041?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum”

4)  Sun BC, Mangione CM, Merchant G, Weiss T, Shalmovitz GZ, Zargaraff G, et al.  External Validation of the San Francisco Syncope Rule.  Ann Emerg Med 2007 Apr; 49 (4):420-7.  Accessed at: “http://www.ncbi.nlm.nih.gov/pubmed/17210201?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=3&log$=relatedarticles&logdbfrom=pubmed”

5)  Birnbaum A, Esses D, BIjur P, Wollowitz A, Gallagher EJ.  Failure to Validate the San Francisco Syncope Rule in an Independent Emergency Department Population.  Ann Emerg Med 2008 Aug; 52(2):151-9.  Accessed at: “http://www.ncbi.nlm.nih.gov/pubmed/18282636?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=2&log$=relatedarticles&logdbfrom=pubmed”

6)  Del  Rosso A, Ungar A, Maggi R, et al. Clinical Predictors of Cardiac Syncope at Initial Evaluation in Patients Referred Urgently to a General Hospital:  The EGSYS Score.  Heart 2008 Dec;94 (12):1620-6.  Accessed at: http://www.ncbi.nlm.nih.gov/pubmed/18519550?ordinalpos=20&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum