Procedure: This clinical
algorithm follows recommendations from resources below along with committee
expertise in areas that published guidelines do not address. This guideline
applies to the older adult population (≥ 65 years).
1.
Follow Trauma Imaging Guidelines
2.
Perform detailed history, physical, medication review.
Determine circumstances leading up to fall (5 types): syncope (LOC or near
LOC), pre-syncope (light-headedness or weakness), situational (sudden fright,
bowel movement or standing), mechanical (trip due to identifiable source) or unknown.
3.
Basic diagnostic testing is to include ECG, CBC, BMP, PT,
PTT and NT-proBNP at physician’s discretion.
4.
Orthostatic blood pressures will be taken if technically
possible as judged by the trauma team. These will be repeated daily for the
duration of the patient’s admission.
5.
Continuous cardiac monitoring
6.
*Note: Most Syncope/pre-syncope patients can be
‘observed’ and not ‘admitted’. Call Utilization review at 3-3070 to clarify
best approach*
7.
Risk Stratification: If the diagnosis is not otherwise
apparent, the clinical indicators below indicate further evaluation.
Cardiopulmonary
a.
Symptoms: Palpitations or
chest pain with syncope, shortness of breath, syncope during exertion, syncope
without warning
b.
Past medical
history: coronary artery disease, structural heart disease, cardiomyopathy,
ventricular arrhythmias, thromboembolism
c.
Family history of sudden cardiac
death
d.
Physical exam findings: systolic
blood pressure < 90mmHg, systolic murmur in right upper sternal border.
e.
Abnormal ECG (Ischemic changes,
bundle branch block, atrioventricular block, prolonged QT interval, heart rate
less than 50 bpm)
f.
Diagnostic Testing: positive troponin
or elevated NT-proBNP >= 200 pg/ML* (*Use the reference range for
Syncope and NOT for CHF/heart failure diagnosis*)
Neurological
a.
History
i.
Headache
ii.
Diplopia
iii.
Aura prior to event
iv.
Prolonged confusion after event with low yield mechanism
v.
Aching muscles after the event
b.
Physical Exam:
i.
Focal neuro deficits (weakness)
ii.
Ataxia
iii.
Aphasia
8.
If any of the above CV or neuro indicators are present,
consider immediate admission to the hospital, consult appropriate service (i.e.
cardiology, neurology) and perform additional workup. Above are independent
predictors of serious cardiac or neurological outcomes.
a.
If cardiopulmonary indicators are present, obtain 2D echocardiography
and consult cardiology.
b.
For neurological indicators, obtain a CTA Head and/or
Carotids per Stroke Alert Consult. If neurological deficits are not explained
by CT, perform MRI head. If seizure possible, order EEG. Consult Neurology. If traumatic
ICH, consult Neurosurgery.
c.
Suspected Pulmonary Embolism: If patient is dyspneic and
history suggestive of PE, obtain spiral CT scan of chest or VQ scan per CT PE
Protocol. Check Modified Wells Criteria
9.
If none of the above indicators are present and cause is
determined to be of benign nature, the patient may be discharged home with
follow-up with patient’s primary care provider and any appropriate specialists.
a.
If neurogenic (orthostatic, medication, after exertion,
situational, vasomotor or carotid hypersensitivity), determine etiology, treat
as indicated, educate on symptom management and refer to outpatient physical
therapy for management. Educate patient on preventing falls (Bedside nurse to
review KRAMES© Fall Prevention Packet with patient and family)
b.
If vestibular hypofunction or benign paroxysmal positional vertigo
(BPPV) are possible, educate on symptom management to prevent falls, refer to
outpatient follow-up with ENT – Otolaryngology and educate patient on
preventing falls (Bedside nurse to review KRAMES© Fall Prevention Packet with
patient and family)
c.
Patients with unexplained syncope can be high users of
Healthcare resources. Consider consulting a Narrative Medicine Facilitator (Robert
Slocum, DMin. PhD, Narrative Medicine Facilitator, (859) 324-0955 or Robert.slocum@uky.edu
Disclaimer: These guidelines are not intended as a directive or to present a
definitive statement of the applicable standard of patient care. They are
offered as an approach for quality assurance and risk management and are
subject to (1) revision as warranted by the continuing evaluation of technology
and practice; (2) the overall individual professional discretion and judgment
of the treating provider in a given patient circumstance; and (3) the patient’s
willingness to follow the recommended treatment.
References
Bignole, M.,
& Hamdan, M.H. (2012). New Concepts in the Assessment of Cardiology. Journal of the American College of
Cardiology, 59(18), doi:10.1016/j.jacc.2011.11.056
European
Society of Cardiology (ESC) Guidelines (2009). Guidelines for the diagnosis and
management of syncope. European Heart
Journal, 30, 2631-2671.
McDermott, MD, D., & Quinn, MD MS, J. (2015). Approach
to the adult patient with syncope in the emergency department. Retrieved from http://www.uptodate.com
Moncure, M.,
& Carlton, L. (2010). Geriatric Trauma Patient Syncope Practice Management
Guidelines. The University of Kansas
Hospital Trauma Policy Manual
Stryjewski
PJ, Nessler B, Kuczaj A, Matusik P, Gilowski W, Nowak J, Nowalany-Kozielska E,
Nessler J. The role of NT-proBNP in the diagnostics and differentiation of
cardiac and reflex syncope in adults: relative importance to clinical
presentation and medical examinations. J Interv Card Electrophysiol. 2014 Oct;41(1):1-8.
