Sunday, March 6, 2016

Syncope and Trauma Guideline



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.




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.

Posted 3/6/16 (A Bernard/S Priest/M Williams); Reviewed 9/26/24 (A Bernard)