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| ==Overview==
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| ==FIRE: Focused Initial Rapid Evaluation==
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| A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.
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| <span style="font-size:85%">Boxes in the salmon color signify that an urgent management is needed.</span>
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| <span style="font-size:85%">'''Abbreviations:''' </span>
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| {{Family tree/start}}
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| {{familytree | | | | | | | | | D01 | | | | | | | | | D01=<div style="text-align: center; width: 15em"> '''Identify cardinal findings that increase the pretest probability of chest pain'''</div> <br> <div style="text-align: left; width: 15em"> ❑ </div>}}
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| {{familytree | | | | | | | | | |!| | | | | | | | | | }}
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| {{familytree | | | | | | | | | A01 | | | | | | | | | | A01= <div style="float: left; text-align: left; width: 15em; padding:1em;">'''Does the patient have any of the findings that require urgent management?'''<br>
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| ❑ [[Tachycardia]] <br> ❑ [[Hypotension]]<br>❑ Severe [[dyspnea]]<br> ❑ <br> ❑ </div>}}
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| {{familytree | | | | | | |,|-|-|^|-|-|.| | | | |}}
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| {{familytree | | | | | | B01 | | | | B02 | | | | B01=<div style=" background: #FA8072; text-align: center; width: 15em; padding:1em;"> {{fontcolor|#F8F8FF|'''Yes'''}} </div>| B02= '''No'''}}
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| {{familytree | | | | | | |!| | | | | |!| | | | }}
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| {{familytree | | | | | | C01 | | | | C02 | | | | C01=<div style=" background: #FA8072; text-align: left; width: 15em; padding:1em;"> {{fontcolor|#F8F8FF| ❑ Immediately order an [[ECG|<span style="color:white;">ECG</span>]]}}<br><br></div> | C02=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''[[Continue with the complete diagnostic approach below]]''' </div>}}
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| {{familytree | | | | | | |!| | | | | | | | | | }}
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| {{familytree | | | | | | G01 | | | | | | | | | G01=<div style=" background: #FA8072; text-align: center; width: 15em; padding:1em;"> {{fontcolor|#F8F8FF| '''[[ECG|<span style="color:white;">ECG</span>]] findings'''}}</div>}}
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| {{familytree | | |,|-|-|-|+|-|-|-|.| | | | |}}
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| {{Family tree/end}}
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| <br><br>
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| ==Complete Diagnostic Approach==
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| A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.
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| <span style="font-size:85%"> '''Abbreviations:''' </span>
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| {{familytree/start}}
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| {{familytree | | | | | | | A01 | | A01= <div style="float: left; text-align: left; width: 20em; padding:1em;">'''Characterize the symptoms:'''<br>
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| ❑ <br>
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| ❑ <br>
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| ❑ <br>
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| ❑ <br>
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| ❑ Activity prior to <br>
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| ❑ </div>}}
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| {{familytree | | | | | | | |!| | | }}
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| {{familytree | | | | | | | L01 | | L01= <div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Inquire about past medical history:'''<br>
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| ❑ Previous episodes<br>
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| ❑ Cardiovascular disease
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| ❑ Neurological diseases </div> }}
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| {{familytree | | | | | | | |!| | | }}
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| {{familytree | | | | | | | B01 | | B01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Identify possible triggers:''' <br>
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| </div>}}
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| {{familytree | | | | | | | |!| | | }}
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| {{familytree | | | | | | | Z01 | | Z01= <div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Examine the patient:'''
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| '''Vitals'''<br>
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| ❑ [[Heart rate]]
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| ❑ [[Blood pressure]]<br>
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| ❑ [[Respiratory rate]]
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| '''Cardiovascular'''<br>
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| '''Respiratory''' <br>
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| ❑ [[Rales]] (suggestive of [[HF]]) <br>
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| '''Neurologic'''<br></div> }}
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| {{familytree | | | | | | | |!| | | }}
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| {{familytree | | | | | | | G01 | | G01= <div style="float: left; text-align: left; width: 20em; padding:1em;">'''Order labs and tests:''' <br> ❑ [[EKG]] ''(most important initial test)''
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| ❑ [[Electrolytes]]
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| ❑ [[Glucose]] (rule out [[hypoglycemia]]) <br> ❑ [[ABG]]
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| </div> }}
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| {{familytree | | | | | | | |!| | | }}
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| {{familytree | | | | | | | H01 | | H01= <div style="float: left; text-align: left; width: 20em; padding:1em;">'''Order imaging studies:'''<br> ❑ '''[[Echocardiography]]''' </div> }}
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| {{familytree | | | | | | | |!| | | }}
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| {{familytree/end}}
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| ==Treatment==
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| Shown below is an algorithm summarizing the therapeutic approach to [[syncope]] based on the 2009 ESC Guidelines for the Diagnosis and Management of Syncope<ref name="pmid19713422">{{cite journal| author=Task Force for the Diagnosis and Management of Syncope. European Society of Cardiology (ESC). European Heart Rhythm Association (EHRA). Heart Failure Association (HFA). Heart Rhythm Society (HRS). Moya A et al.| title=Guidelines for the diagnosis and management of syncope (version 2009). | journal=Eur Heart J | year= 2009 | volume= 30 | issue= 21 | pages= 2631-71 | pmid=19713422 | doi=10.1093/eurheartj/ehp298 | pmc=PMC3295536 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19713422 }} </ref> and the 2006 AHA/ACCF Scientific Statement on the Evaluation of Syncope.<ref name="Strickberger2006">{{cite journal|last1=Strickberger|first1=S. A.|title=AHA/ACCF Scientific Statement on the Evaluation of Syncope: From the American Heart Association Councils on Clinical Cardiology, Cardiovascular Nursing, Cardiovascular Disease in the Young, and Stroke, and the Quality of Care and Outcomes Research Interdisciplinary Working Group; and the American College of Cardiology Foundation: In Collaboration With the Heart Rhythm Society: Endorsed by the American Autonomic Society|journal=Circulation|volume=113|issue=2|year=2006|pages=316–327|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.105.170274}}</ref>
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| <span style="font-size:85%">'''Abbreviations:''' '''AF:''' Atrial fibrillation; '''SVT:''' Supraventricular tachycardia; '''VT:''' Ventricular tachycardia; '''MI:''' Myocardial infarction; '''BBB:''' Bundle branch block. </span>
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| {{familytree/start}}
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| {{familytree | | | | | A00 | | | | | | A00= '''Determine the etiology'''}}
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| {{familytree | |,|-|-|-|+|-|-|-|.| |}}
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| {{familytree | A01 | | A02 | | A03 | A01= '''Cardiovascular syncope'''| A02= '''Reflex Syncope'''| A03= '''[[Orthostatic hypotension]]'''}}
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| {{familytree | |!| | | |!| | | |!| | }}
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| {{familytree | D01 | | D02 | | D03 | | | D03= <div style="float: left; text-align: left; width: 24em"> ❑ Explain the diagnosis and provide reassurance ([[ESC#Classes of Recommendations|Class I; Level of Evidence: C]])<br> ❑ Explain the risk of recurrence and educate regarding avoidance of [[Vasovagal syncope#Triggers|triggers]] ([[ESC#Classes of Recommendations|Class I; Level of Evidence: C]]) <br> ❑ Educate patients with prodrome about isometric physical counterpressure maneuvers (PCM) ([[ESC#Classes of Recommendations|Class I; Level of Evidence: B]]):
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| : ❑ Hand grip and arm tensing
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| : ❑ Leg crossing <br>
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| ❑ Consider [[cardiac pacing]] in:
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| : ❑ Dominant cardioinhibitory [[carotid sinus syndrome]] ([[ESC#Classes of Recommendations|Class IIa; Level of Evidence: B]])
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| : ❑ Recurrent reflex syncope, age >40 years and spontaneous cardioinhibitory response during monitoring ([[ESC#Classes of Recommendations|Class IIa; Level of Evidence: B]])</div>
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| | D02= <div style="float: left; text-align: left; width: 24em"> ❑ Provide adequate hydration and salt intake ([[ESC#Classes of Recommendations|Class I; Level of Evidence: C]])<br> ❑ Provide additional therapy if needed: | |
| : ❑ Administer [[midodrine]] 10 mg PO every 8 hours ([[ESC#Classes of Recommendations|Class IIa; Level of Evidence: B]])
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| <span style="font-size:85%;color:red">Contraindicated in severe heart disease, acute renal failure, pheochromocytoma, severe hypertension or thyrotoxicosis </span> <br>OR<br>
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| : ❑ Administer [[fludrocortisone]]''' 0.1 mg/day PO ([[ESC#Classes of Recommendations|Class IIa; Level of Evidence: C]]) <br>
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| ❑ Educate patients about isometric physical counterpressure maneuvers (PCM) ([[ESC#Classes of Recommendations|Class IIb; Level of Evidence: C]]) <br> ❑ Position the patient in a head-up tilt sleeping position (>10°) to increase fluid volume ([[ESC#Classes of Recommendations|Class IIb; Level of Evidence: C]]) </div> | D01=<div style="float: left; text-align: left; width: 24em; padding:1em;"> ❑ Treat the [[arrhythmia]] according to the type <br>
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| ❑ Schedule for [[cardiac pacing]] surgery in patients with:
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| : ❑ [[Sinus node disease]] ([[ESC#Classes of Recommendations|Class I; Level of Evidence: C]])
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| : ❑ [[Second degree AV block classification|Mobitz II AV block]] or [[complete AV block]] ([[ESC#Classes of Recommendations|Class I; Level of Evidence: B]])
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| : ❑ [[BBB]] with positive [[electrophysiological study]] ([[ESC#Classes of Recommendations|Class I; Level of Evidence: B]]) <br>
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| ❑ Schedule for [[catheter ablation]] in patients with:
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| : ❑ [[SVT]] ([[ESC#Classes of Recommendations|Class I; Level of Evidence: C]])
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| : ❑ [[VT]] ([[ESC#Classes of Recommendations|Class I; Level of Evidence: C]])
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| : ''In absence of [[structural hearth disease]]'' <br>
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| ❑ Administer [[atrial fibrillation resident survival guide#Maintenance of Sinus Rhythm|antiarrhythmic drug therapy]] in patients with:
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| : ❑ [[AF]] ([[ESC#Classes of Recommendations|Class IIa; Level of Evidence: C]])
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| : ❑ Failed [[catheter ablation]] ([[ESC#Classes of Recommendations|Class I; Level of Evidence: C]])<br>
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| ❑ Schedule for [[implantable cardioverter defibrillator]] surgery in patients with:
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| : ❑ [[VT]] with [[heart disease]] ([[ESC#Classes of Recommendations|Class I; Level of Evidence: B]])
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| : ❑ Electrophysiological study induced [[VT]] with previous [[MI]] ([[ESC#Classes of Recommendations|Class I; Level of Evidence: B]])
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| : ❑ [[VT]] with inherited [[cardiomyopathy]] or [[channelopathy]] ([[ESC#Classes of Recommendations|Class IIa; Level of Evidence: B]])</div>}}
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| {{familytree/end}}
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| ==Do's==
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| * Consider a [[tilt test]]:
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| ** To differentiate between reflex [[syncope]] and [[orthostatic hypotension]] ([[ESC#Classes of Recommendations|Class IIa; Level of Evidence: C]])
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| ** If syncope is due to a [[psychiatric disease]] ([[ESC#Classes of Recommendations|Class IIb; Level of Evidence: C]])
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| ** To differenciate [[syncope]] with jerking movements from [[epilepsy]] ([[ESC#Classes of Recommendations|Class IIb; Level of Evidence: C]])
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| ** If [[syncope]] happened after standing up from a seated position due to possible [[orthostatic hypotension]]([[ESC#Classes of Recommendations|Class IIb; Level of Evidence: C]])
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| * Consider implantable loop recorder before [[cardiac pacing]] in patients with suspected or confirmed reflex [[syncope]] presenting with frequent or traumatic syncopal episodes.
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| * Perform exercise testing in patients who experience syncope during or after exertion ([[ESC#Classes of Recommendations|Class I; Level of Evidence: C]]).
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| ==Don'ts==
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| * Don't perform [[carotid sinus massage]] in patients with previous [[TIA]] or [[stroke]] within the past 3 months and in patients with [[carotid sinus]] bruits unless [[carotid sinus]] [[doppler]] studies excluded significant stenosis ([[ESC#Classes of Recommendations|Class III; Level of Evidence: C]]).
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| * Don't perform [[tilt test|tilt testing]] for the assessment of response to treatment. ([[ESC#Classes of Recommendations|Class III; Level of Evidence: B]]).
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| * Don't perform [[tilt test|isoproterenol tilt test]] in patients with [[ischemic heart disease]] ([[ESC#Classes of Recommendations|Class III; Level of Evidence: C]]).
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| * Don't use [[adenosine]] [[stress test]] as a diagnostic test to select patients for [[cardiac pacing]] due to the lack of correlation with spontaneous [[syncope]] ([[ESC#Classes of Recommendations|Class III; Level of Evidence: B]]).
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| * Don't perform [[electrophysiologic study]] if there is already indication for [[implantable cardioverter defibrillator]] in patients with [[ischemic heart disease]] with suspected [[arrhythmia|arrhythmic]] cause.
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| * Don't perform [[electrophysiologic study]] in patients with normal [[ECG]], no [[heart disease]] and no [[palpitations]] unless non-syncopal [[LOC]] is suspected ([[ESC#Classes of Recommendations|Class III; Level of Evidence: B]]).
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| * Don't give [[beta blockers]] for patients with reflex syncope ([[ESC#Classes of Recommendations|Class III; Level of Evidence: A]]).
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| ==References==
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| {{Reflist|2}}
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| [[Category:Cardiology]]
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| [[Category:Resident survival guide]]
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| [[Category:Up-To-Date]]
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| [[Category:Emergency]]
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| {{WikiDoc Help Menu}}
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