The EM Educator Series: Why does my patient keep passing out?

Author: Alex Koyfman, MD (@EMHighAK) and Diana Coleman, MD // Edited by: Brit Long, MD (@long_brit) and Manpreet Singh (@MprizzleER )

Welcome to this week’s EM Educator Series. These posts provide brief mini-cases followed by key questions to consider while working. The featured questions provide important learning points for those working with you, as well as vital items to consider in the evaluation and management of the specific condition discussed.

This week has another downloadable PDF document with questions, links and answers you can share with learners as educators in #MedEd. We are working on retroactively doing this for the past posts as well. Please message us over Twitter and let us know if you have any feedback on ways to improve this for you. Enjoy!

Mini Case: Why does my patient keep passing out?

A 54-year-old male presents with recurrent syncopal episodes. He has been experiencing multiple episodes of passing out with convulsions that last less than 20 seconds. There is no post ictal state or incontinence. The family and patient are concerned about seizures. However, this is sounding more and more like something other than a seizure…

Considerations:

1. Syncope & EKG findings you should consider
2. Is there utility in obtaining orthostatic vital signs?
3. What is the ED work-up of syncope? Do you need a troponin and head CT?
4. What is the risk stratification of syncope patients, and what red flags should you consider?
5. What patients are appropriate for discharge? Who requires admission?
6. Syncope chameleons/mimics… What else should you consider?

Suggested Resources:

• Articles:
  • https://lifeinthefastlane.com/ecg-library/smacc-workshop-deadly-diagnoses/
  • http://www.emdocs.net/syncope-ed-updates-2017-aha-acc-hrs-clinical-policy/
  • http://hqmeded-ecg.blogspot.com/2015/04/ed-syncope-workup-after-h-and-p-ecg-is.html
  • https://lifeinthefastlane.com/futility-orthostatic-measurements/
  • https://emlyceum.com/2015/06/17/syncope-answers/
  • http://rebelem.com/predicting-dysrhythmias-after-syncope/
  • https://www.aliem.com/2013/04/management-of-syncope-aka-done-fell-out/
  • http://www.emdocs.net/syncope-the-latest-on-clinical-work-up-and-management/
  • http://www.emdocs.net/vascular-causes-of-syncope/
  • https://www.ncbi.nlm.nih.gov/pubmed/29110977
• Podcast:
  • https://emergencymedicinecases.com/episode-25-pediatric-adult-syncope/
• Calculators:
  • https://www.mdcalc.com/egsys-evaluation-guidelines-syncope-study-score-syncope
  • https://www.mdcalc.com/san-francisco-syncope-rule