Syncope
May 2005
Syncope
Search Strategy: Utilizing OVID from 1966 until present you perform a search using the search terms syncope (including all subheadings 6,613 “hits”), prognosis (441,968 “hits”), and clinical decision rule (limited to subject heading ‘decision support techniques’ 35,514 “hits”). Combining the results of syncope and prognosis findings you narrow your findings to 441 articles which you narrow further to 139 by limiting to English and Core Clinical Journals. Combining syncope and clinical decision rule findings, you narrow the article number to 24. Scanning through these articles you pick out the four articles noted below.
A 48 year old male presents to your ED by ambulance with a chief complaint of “passing out”. He recalls walking along the sidewalk when he began feeling nauseous and then light-headed. He remembers nothing else except awakening on the ground surrounded by people, including the paramedics. EMS personnel report a groggy, but awake patient when they arrived with no eyewitness reports of seizure-like activity. The patient reports no past medical history, including no prior syncopal episodes. Currently, he feels at his baseline state of good health and denies all symptoms on review of systems including chest pain and dyspnea.
On physical exam you note the following vital signs: BP 115/80, P 72, R 18, T 36.7°, 98% on room air. His examination, including cardiac and neurological evaluation, is unremarkable. An EKG shows normal sinus rhythm with normal axis and intervals with no old EKG for comparison.
In formulating your differential diagnosis, you contemplate the myriad diagnostic possibilities of syncope and several questions come to mind. What is the short-term and long-term prognosis after a first episode of syncope? How do I decide who should be admitted and who should be discharged for outpatient evaluation?
PICO Question
Population: Middle-aged male with syncope
Intervention: Inpatient Evaluation
Comparison: Outpatient (or no) Evaluation
Outcome: Recurrent syncope, seizure, myocardial infarction, death
Years
First years: Clinical Policy: Critical Issues in the Evaluation and Management of Patients Presenting With Syncope. Annals EM 2001; 37: 771-776.
Second years: Incidence and Prognosis of Syncope. NEJM 2002; 347: 878-885.
Third years: Derivation of the San Francisco Syncope Rule to Predict Patients with Short-Term Serious Outcomes. Annals EM 2004; 43: 224-232.
Fourth years: Syncope Evaluation in the Emergency Department Study (SEEDS): A Multidisciplinary Approach to Syncope Management. Circulation 2004; 110: 3636-3645.
Forms
First Year Residents: use the Clinical Practice Guidelines Critical Review Form
Second Year Residents: use the Prognosis Critical Review Form
Third Year Residents: use the Clinical Decision Rule Critical Review Form
Fourth Year Residents: use the Therapy Critical Review Form
Articles
Article 1: Clinical Policy: Critical Issues in the Evaluation and Management of Patients with Syncope, Annals EM 2001; 37: 771-776
ANSWER KEY
Article 2: Incidence and Prognosis of Syncope, NEJM 2002; 347: 878-885
ANSWER KEY
Article 3: Derivation of the San Francisco Syncope Rule to Predict Patients with Short-term Serious Outcomes, Annals EM 2004; 43: 224-232
ANSWER KEY
Article 4: Syncope Evaluation in the Emergency Department Study (SEEDS): A Multidisciplinary approach to Syncope Management, Circulation 2004; 110: 3636-3645
ANSWER KEY