Sandbox/AL: Difference between revisions
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'''Vitals'''<br> | '''Vitals'''<br> | ||
❑ [[Heart rate]] | ❑ [[Heart rate]] | ||
❑ [[Blood pressure]]<br> | ❑ [[Blood pressure]]<br> | ||
❑ [[Respiratory rate]] | ❑ [[Respiratory rate]] | ||
'''Cardiovascular'''<br> | |||
'''Respiratory''' <br> | '''Respiratory''' <br> | ||
❑ [[Rales]] (suggestive of [[HF]]) <br> | ❑ [[Rales]] (suggestive of [[HF]]) <br> | ||
'''Neurologic'''<br></div> }} | |||
'''Neurologic'''<br> | |||
{{familytree | | | | | | | |!| | | }} | {{familytree | | | | | | | |!| | | }} | ||
{{familytree | | | | | | | G01 | | G01= <div style="float: left; text-align: left; width: 20em; padding:1em;">'''Order labs and tests:''' <br> ❑ [[EKG]] ''(most important initial test)'' | {{familytree | | | | | | | G01 | | G01= <div style="float: left; text-align: left; width: 20em; padding:1em;">'''Order labs and tests:''' <br> ❑ [[EKG]] ''(most important initial test)'' | ||
❑ [[Electrolytes]] | ❑ [[Electrolytes]] | ||
❑ [[Glucose]] (rule out [[hypoglycemia]]) <br> ❑ [[ABG]] | ❑ [[Glucose]] (rule out [[hypoglycemia]]) <br> ❑ [[ABG]] | ||
</div> }} | |||
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{{familytree | | | | | | | H01 | | H01= <div style="float: left; text-align: left; width: 20em; padding:1em;">'''Order imaging studies:'''<br> ❑ '''[[Echocardiography]]''' | {{familytree | | | | | | | H01 | | H01= <div style="float: left; text-align: left; width: 20em; padding:1em;">'''Order imaging studies:'''<br> ❑ '''[[Echocardiography]]''' </div> }} | ||
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==Treatment== | ==Treatment== |
Revision as of 15:54, 23 April 2014
Overview
FIRE: Focused Initial Rapid Evaluation
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.
Boxes in the salmon color signify that an urgent management is needed.
Abbreviations:
Identify cardinal findings that increase the pretest probability of chest pain ❑ | |||||||||||||||||||||||||||||||||||||||
Does the patient have any of the findings that require urgent management? ❑ Tachycardia ❑ Hypotension ❑ Severe dyspnea ❑ ❑ | |||||||||||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||||||||||
ECG findings | |||||||||||||||||||||||||||||||||||||||
Complete Diagnostic Approach
A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.
Abbreviations:
Characterize the symptoms: ❑ | |||||||||||||||||||||
Inquire about past medical history: ❑ Previous episodes | |||||||||||||||||||||
Identify possible triggers: | |||||||||||||||||||||
Examine the patient:
Vitals
| |||||||||||||||||||||
Order labs and tests: ❑ EKG (most important initial test) ❑ Electrolytes
❑ Glucose (rule out hypoglycemia) | |||||||||||||||||||||
Order imaging studies: ❑ Echocardiography | |||||||||||||||||||||
Treatment
Shown below is an algorithm summarizing the therapeutic approach to syncope based on the 2009 ESC Guidelines for the Diagnosis and Management of Syncope[1] and the 2006 AHA/ACCF Scientific Statement on the Evaluation of Syncope.[2]
Abbreviations: AF: Atrial fibrillation; SVT: Supraventricular tachycardia; VT: Ventricular tachycardia; MI: Myocardial infarction; BBB: Bundle branch block.
Determine the etiology | |||||||||||||||||||||||||
Cardiovascular syncope | Reflex Syncope | Orthostatic hypotension | |||||||||||||||||||||||
❑ Treat the arrhythmia according to the type ❑ Schedule for cardiac pacing surgery in patients with:
❑ Schedule for catheter ablation in patients with:
❑ Administer antiarrhythmic drug therapy in patients with: ❑ Schedule for implantable cardioverter defibrillator surgery in patients with:
| ❑ Provide adequate hydration and salt intake (Class I; Level of Evidence: C) ❑ Provide additional therapy if needed: Contraindicated in severe heart disease, acute renal failure, pheochromocytoma, severe hypertension or thyrotoxicosis
❑ Position the patient in a head-up tilt sleeping position (>10°) to increase fluid volume (Class IIb; Level of Evidence: C) | ❑ Explain the diagnosis and provide reassurance (Class I; Level of Evidence: C) ❑ Explain the risk of recurrence and educate regarding avoidance of triggers (Class I; Level of Evidence: C) ❑ Educate patients with prodrome about isometric physical counterpressure maneuvers (PCM) (Class I; Level of Evidence: B):
❑ Consider cardiac pacing in:
| |||||||||||||||||||||||
Do's
- Consider a tilt test:
- To differentiate between reflex syncope and orthostatic hypotension (Class IIa; Level of Evidence: C)
- If syncope is due to a psychiatric disease (Class IIb; Level of Evidence: C)
- To differenciate syncope with jerking movements from epilepsy (Class IIb; Level of Evidence: C)
- If syncope happened after standing up from a seated position due to possible orthostatic hypotension(Class IIb; Level of Evidence: C)
- Consider implantable loop recorder before cardiac pacing in patients with suspected or confirmed reflex syncope presenting with frequent or traumatic syncopal episodes.
- Perform exercise testing in patients who experience syncope during or after exertion (Class I; Level of Evidence: C).
Don'ts
- 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 (Class III; Level of Evidence: C).
- Don't perform tilt testing for the assessment of response to treatment. (Class III; Level of Evidence: B).
- Don't perform isoproterenol tilt test in patients with ischemic heart disease (Class III; Level of Evidence: C).
- 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 (Class III; Level of Evidence: B).
- Don't perform electrophysiologic study if there is already indication for implantable cardioverter defibrillator in patients with ischemic heart disease with suspected arrhythmic cause.
- Don't perform electrophysiologic study in patients with normal ECG, no heart disease and no palpitations unless non-syncopal LOC is suspected (Class III; Level of Evidence: B).
- Don't give beta blockers for patients with reflex syncope (Class III; Level of Evidence: A).
References
- ↑ 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. (2009). "Guidelines for the diagnosis and management of syncope (version 2009)". Eur Heart J. 30 (21): 2631–71. doi:10.1093/eurheartj/ehp298. PMC 3295536. PMID 19713422 Check
|pmid=
value (help). - ↑ Strickberger, S. A. (2006). "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". Circulation. 113 (2): 316–327. doi:10.1161/CIRCULATIONAHA.105.170274. ISSN 0009-7322.