#442 Syncope: Live from SHM #Converge24 with Dr. Dan Dressler
Jun 3, 2024
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Dr. Dan Dressler from Emory University shares insights on managing syncope cases. Topics covered include categorizing syncope, initial workup, risk scores, cardiac evaluation, and take-home points for safely discharging low-risk patients. The podcast delves into a framework for understanding different syncope types, strategies for high-risk cases, and the link between syncope and pulmonary embolism.
Recognize seizure indicators during syncope: lateral tongue biting, urinary incontinence, and prolonged post-ictal state.
Tailor syncope workup with EKG, orthostatic vital signs, and judicious use of additional tests based on clinical presentation.
Consider individualized PE risk in syncope cases, balancing D-dimer testing and imaging for optimized patient outcomes.
Deep dives
Differentiating Syncope from Seizure
In evaluating a syncope episode, it is critical to distinguish it from seizure. Key indicators of seizure during a syncope episode include lateral tongue biting, urinary incontinence, and a post-ictal state lasting for an extended period. Moreover, myoclonic jerks commonly seen post-syncope are not indicative of seizure if brief and usually last for a few seconds. Understanding these distinctions helps in accurate diagnosis and appropriate management.
Diagnostic Testing for Syncope
Diagnostic testing for syncope often involves a thorough history, physical examination, orthostatic vital signs assessment, and an electrocardiogram (EKG). While considering additional tests, such as D-dimer and imaging for pulmonary embolism (PE), it is crucial to tailor the workup based on the patient's history, physical findings, and risk factors for syncope causes like orthostatic hypotension, arrhythmias, or structural heart issues. A structured approach combining clinical judgment with targeted investigations enhances diagnostic accuracy.
PE Considerations in Syncope Evaluations
Addressing the potential link between syncope and pulmonary embolism (PE) requires a strategic approach informed by recent studies like PESIT trial findings. While syncope patients rarely present with PE, those with higher risk factors or inconclusive diagnoses may benefit from D-dimer testing and imaging protocols tailored to their clinical profile. Balancing the risk of PE with comprehensive syncope assessment underscores the importance of individualized care decisions to optimize patient outcomes.
Understanding the Relationship Between D-Dimers and Pulmonary Embolisms
The podcast discusses the correlation between D-dimers and the likelihood of having pulmonary embolisms (PEs). Studies have shown that when patients with positive D-dimer test results or a positive well score are imaged, about two-thirds of them have large PEs. However, the remaining one-third may have smaller segmental or subsegmental PEs. The episode delves into the possibility that even these smaller PEs, which may not cause complete vascular obstruction, could potentially trigger vasovagal episodes through lung inflammation activation.
Evaluation and Management of Syncope Cases
In the podcast episode, a case of a patient named Tamara is presented, who experiences syncope with jerking movements. The discussion addresses the approach to evaluating syncope cases, emphasizing the importance of conducting a Canadian syncope risk assessment to determine the patient's risk level based on history, physical exam, and EKG findings. The episode touches on the decision-making process regarding further testing, such as brain imaging or EEG, highlighting that in cases like Tamara's with short-duration jerking movements and no post-ictal state, brain imaging or EEG may not be necessary. Additionally, counseling patients post-syncope event, providing reassurance, and recommending basic self-care measures like hydration are essential aspects of patient management.
Stand up to syncope as Dr. Dan Dressler (Emory University) guides us to confidently manage cases! We review a framework for understanding different types of syncope, and strategies for determining which low-risk patients can be safely discharged, and appropriate next steps to work up those high-risk and in-between cases.
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