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 ❑ Irregularly irregular rhythm (suggestive of AF) ❑ Tachycardia (suggestive of orthostatic hypotension, cardiovascular or reflex syncope) ❑ Bradycardia (suggestive of cardiovascular syncope) ❑ Blood pressure ❑ Measure in both arms, while standing and supine ❑ Orthostatic hypotension (Fall in systolic BP ≥ 20 mmHg and/or in diastolic BP of at least≥ 10 mmHg between the supine and sitting BP reading) ❑ Hypertension (suggestive of cardiovascular syncope) ❑ Respiratory rate ❑ Tachypnea (suggestive of reflex syncope) Respiratory ❑ Rales (suggestive of HF) Cardiovascular ❑ Palpitations (suggestive of arrhythmia) ❑ Carotid bruits (suggestive of cardiovascular syncope) ❑ Murmurs ❑ Aortic stenosis: crescendo-decrecendo systolic ejection murmur best heard at the upper right sternal border ❑ Pulmonary stenosis: systolic ejection murmur best heard at the left second intercostal space ❑ Heart sounds ❑ Loud P2 (suggestive of pulmonary hypertension) Neurologic ❑ Focal abnormalities (suggestive of stroke or cerebral mass) ❑ Hemiparesis ❑ Vision loss ❑ Aphasia ❑ Hypertonia ❑ Glasgow coma scale ❑ Signs suggestive of Parkinson's disease: ❑ Tremor ❑ Rigidity ❑ Bradykinesia/Akinesia ❑ Postural instability ❑ Shuffling gait

Order labs and tests: ❑ EKG (most important initial test) ❑ Myocardial infarction ❑ Tachyarrhythmia ❑ Heart block ❑ Bradyarrhythmia ❑ Long or short QT ❑ Bradyarrhythmia ❑ Electrolytes ❑ Hyponatremia ❑ Hypernatremia ❑ Hypokalemia ❑ Glucose (rule out hypoglycemia) ❑ ABG ❑ Hypoxia ❑ Hypocapnea (suggestive of tachypnea, rule out psychiatric disease)

Order imaging studies: ❑ Echocardiography in case of: ❑ Structural heart disease ❑ Myocardial infarction ❑ Cardiac valve disease ❑ Head CT in case of: ❑ Head trauma ❑ TIA

Confirm diagnosis of syncope Must have this 3 characteristics: ❑ Short duration, AND ❑ Rapid onset, AND ❑ Complete spontaneous recovery

Syncope

Non-syncopal LOC

Known etiology

Unknown etiology

Consider additional tests ❑ Stool guaiac test (rule out GI bleeding) ❑ Blood and urine toxicology tests (rule out intoxication)

Determine the etiology: ❑ Cardiovascular ❑ Arrhythmia ❑ Cardiac ischemia ❑ Structural heart disease ❑ Orthostatic hypotension ❑ Syncope after standing up and documentation of orthostatic hypotension (Class I; Level of Evidence: C) ❑ Reflex ❑ Vasovagal syncope precipitated by emotional distress and associated with typical prodome (Class I; Level of Evidence: C) ❑ Situational syncope during or after specific triggers (Class I; Level of Evidence: C)

Determine if there are any high risk criteria: ❑ Severe structural heart disease ❑ CAD ❑ Clinical or ECG features suggesting arrhythmic syncope ❑ Syncope during exertion or supine ❑ Palpitations at the time of syncope ❑ Family history of SCD ❑ Non-sustained VT ❑ Conduction abnormalities with QRS >120 ms ❑ Sinus bradycardia ❑ Preexcitation syndrome ❑ Long or short QT ❑ Brugada pattern ❑ ARVC ❑ Important comorbidities ❑ Severe anemia ❑ Electrolyte disturbance

Consider alternative diagnoses: ❑ With loss of consciousness ❑ Epilepsy ❑ Inquire about suggestive signs include aura, prolonged confusion, muscle ache ❑ Inquire about past medical history ❑ Perform neurological evaluation (Class I; Level of Evidence: C) ❑ Perform tilt testing (Class IIb; Level of Evidence: C), preferably with concurrent EEG and video monitoring if doubt of mimicking epilepsy ❑ Intoxication ❑ Vertebrobasilar TIA ❑ Without loss of consciousness ❑ Cataplexy ❑ Drop attacks ❑ Functional /psychogenic pseudosyncope ❑ Perform a psychiatric evaluation (Class I; Level of Evidence: C) ❑ TIA of carotid origin

High risk

Low risk

❑ Immediate in-hospital monitoring (in bed or telemetry) to look for abnormalities suggestive of arrhythmic syncope (Class I; Level of Evidence: B)

Recurrent episodes of syncope ❑ Order a Holter if > 1 episode/week (Class I; Level of Evidence: B) ❑ Order external loop recorder (ELR) if interval between episodes < 4 weeks (Class IIa; Level of Evidence: B) ❑ Perform carotid sinus massage in patients > 40 years with uncertain syncopal etiology (Class I; Level of Evidence: B) Contraindicated in patients with previous TIA or stroke in the past 3 months Contraindicated in patients with carotid bruits

Single episode of syncope

In case of suspicion of structural heart disease: ❑ Order an echocardiography (Class I; Level of Evidence: B)

Is any of the following high risk setting present? ❑ Potential risk of physical injury ❑ Occupational implications

Presence of structural heart disease

Absence of structural heart disease

Yes

No

❑ Treat accordingly

Perform a tilt test (Class I; Level of Evidence: B)

No further investigation

❑ No findings, OR ❑ Reflex syncope: induction of hypotension or bradycardia with reproduction of syncope (Class I; Level of Evidence: B), OR ❑ Orthostatic hypotension: induction of progressive orthostatic hypotension with or without symptoms (Class I; Level of Evidence: B)

Diagnostic Clues

Diagnostic clues for the etiologies of syncope Cardiovascular syncope Reflex syncope Orthostatic hypotension Diagnostic criteria ❑ Arrhythmia and cardiac ischemia-related syncope diagnosed by ECG specific findings (Class I; Level of Evidence: C) ❑ Cardiovascular syncope due structural heart disease (Class I; Level of Evidence: C) Additional findings ❑ Presence of definitive structural hearth disease ❑ Aortic stenosis ❑ Acute myocardial infarction ❑ Hypertrophic cardiomyopathy ❑ Pericardial disease ❑ Cardiac tumors ❑ Family history of unexplained sudden death ❑ Syncope during exertion or supine ❑ Abnormal ECG findings ❑ Sudden onset of palpitations before syncope Abnormal ECG findings ❑ Mobitz I second degree AV block ❑ Non-sustained VT ❑ Premature QRS complexes ❑ Wide QRS(≥ 0.12 s) ❑ Long or short QT intervals ❑ Early repolarization ❑ Q waves (myocardial infarction) ❑ Bifascicular block Diagnostic criteria ❑ Syncope after standing up and documentation of orthostatic hypotension (Class I; Level of Evidence: C) Additional findings ❑ Syncope after prolonged standing ❑ New antihypertensive drug or dosage change ❑ Presence of autonomic neuropathy ❑ Prolonged standing ❑ Associated with crowd or hot spaces Diagnostic criteria ❑ Vasovagal syncope precipitated by emotional distress and is associated with typical prodome (Class I; Level of Evidence: C) ❑ Situational syncope during or after specific triggers (Class I; Level of Evidence: C) ❑ Carotid sinus hypersensitivity if syncope is reproduced in the presence of asystole > 3 sec and/or fall in systolic blood pressure > 50 mmHg (Class I; Level of Evidence: B) Additional findings ❑ Absence of heart disease ❑ History of recurrent syncope ❑ After unpleasant sight, smell, sound or pain ❑ Associated to nausea or vomit ❑ Prolonged standing ❑ Associated with crowd or hot spaces ❑ Head rotation or pressure to carotid sinus ❑ After exertion ❑ Postprandial

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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