Sandbox/AL

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

❑ Immediately order an ECG

Continue with the complete diagnostic approach below

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: ❑ ❑ ❑ ❑ ❑ Activity prior to ❑

Inquire about past medical history: ❑ Previous episodes ❑ Cardiovascular disease ❑ Neurological diseases

Identify possible triggers:

Examine the patient: Vitals ❑ Heart rate ❑ Blood pressure ❑ Respiratory rate Cardiovascular Respiratory ❑ Rales (suggestive of HF) Neurologic

Order labs and tests: ❑ EKG (most important initial test) ❑ Electrolytes ❑ Glucose (rule out hypoglycemia) ❑ ABG

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 and the 2006 AHA/ACCF Scientific Statement on the Evaluation of Syncope.

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: ❑ Sinus node disease (Class I; Level of Evidence: C) ❑ Mobitz II AV block or complete AV block (Class I; Level of Evidence: B) ❑ BBB with positive electrophysiological study (Class I; Level of Evidence: B) ❑ Schedule for catheter ablation in patients with: ❑ SVT (Class I; Level of Evidence: C) ❑ VT (Class I; Level of Evidence: C) In absence of structural hearth disease ❑ Administer antiarrhythmic drug therapy in patients with: ❑ AF (Class IIa; Level of Evidence: C) ❑ Failed catheter ablation (Class I; Level of Evidence: C) ❑ Schedule for implantable cardioverter defibrillator surgery in patients with: ❑ VT with heart disease (Class I; Level of Evidence: B) ❑ Electrophysiological study induced VT with previous MI (Class I; Level of Evidence: B) ❑ VT with inherited cardiomyopathy or channelopathy (Class IIa; Level of Evidence: B)

❑ Provide adequate hydration and salt intake (Class I; Level of Evidence: C) ❑ Provide additional therapy if needed: ❑ Administer midodrine 10 mg PO every 8 hours (Class IIa; Level of Evidence: B) Contraindicated in severe heart disease, acute renal failure, pheochromocytoma, severe hypertension or thyrotoxicosis OR ❑ Administer fludrocortisone 0.1 mg/day PO (Class IIa; Level of Evidence: C) ❑ Educate patients about isometric physical counterpressure maneuvers (PCM) (Class IIb; Level of Evidence: C) ❑ 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): ❑ Hand grip and arm tensing ❑ Leg crossing ❑ Consider cardiac pacing in: ❑ Dominant cardioinhibitory carotid sinus syndrome (Class IIa; Level of Evidence: B) ❑ Recurrent reflex syncope, age >40 years and spontaneous cardioinhibitory response during monitoring (Class IIa; Level of Evidence: B)

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

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