my first lecture this morning is about Syncopy in some ways um this is a whole new topic in some ways I'm going to be a broken record it's the same old same old same old it's about how in emergency medicine one of our jobs is finding that really dangerous needle in the hay stack and how we finally starting to realize that searching for that needle can cause harm and we have to not only consider how important it is not to miss the needle but also how harmful it can be if we look the wrong way and Syncopy is as good an example of this as any because it's really pretty simple um Syncopy most of the time somebody comes in they passed out or they almost passed out doesn't matter and um and most of them are fine of the 10 15% depending upon what your population is if you start with old people with heart disease maybe more but of the group that isn't fine the vast majority of them are obvious right in front of you so it's pretty easy the ones who look sick they have abnormal pulse they have abnormal vital signs they're altered they're you know they're not normal those are easy then there's the large group who look great and most of them if you did nothing would be great so our job is to find the occasional one maybe one out of a 100 in that group who looks great maybe depending upon the population a few out of 100 but it's a small number who actually have something really important that you don't want to miss and now we're going to consider as well how do you do that in not miss them in a way that doesn't cause harm because if you don't want to miss anybody ever you got to admit them all and keep them in the hospital Forever on monitoring and that's crazy so what we want to do is try to increase our chance of finding the sick one without at the same time doing a lot of harm to all the healthy ones so let's go step back for and that's all this chapter is about we're going to spend a few minutes on some details about that um but before we do let's think conceptually again what is syncopy why do people have Syncopy what's the mechanism you all know this but think about it because it's it's useful to go through it in your brain blood brain loss of blood for the brain and it's not focal it's generalized so when you have focal blood flow loss you get a stroke right or a Tia or something like that you get a focal deficit cuz one specific area of the brain isn't working when you get a global loss the overall the brain doesn't work and you lose Consciousness now um so you can get that for a lot of reasons but what's the really important reason why you get sudden it's usually sudden Global loss of blood flow to the brain okay arhythmia now there's one other thing about and that's the answer okay that's the key answer if you want to know what to worry about that's it period arhythmia okay now before we go further there's one other thing about Syncopy that's really really important it's Global loss of blood flow to the brain but there's one other characteristic that we didn't mention which is the timing What's the timing it's transient well yes we're going to get back to that in a second but it's transient right cuz if it's not transient it's not Syncopy then it's altered mental status alter mental status is something very very different altered mental status we deal with a lot right and we have to know how to work that up we're not going to talk about that now but this is somebody who is walking around suddenly loses blood flow of the brain and becomes unconscious or near unconscious and then is better again so think about the causes of Syncopy in a textbook somebody give me a a a list of causes of Syncopy in any textbook hypoglycemia hypoglycemia does hypoglycemia cause Syncopy absolutely not every time a resident sends off a sugar I think to myself you must not be thinking because how could you have a blood sugar of 20 that makes you pass out that now you're normal what automatically your blood sugar came up to 100 and if it magically did it was 20 for a second and now it's 100 it will be 100 you won't learn anything by the blood sugar if the person's normal in front of you their blood sugar isn't 20 and the same is true for all those many other labs so I see lots of people getting Labs that make no sense Syncopy is a transient event it comes and it goes so that's really important to think about that if you have somebody has altered metal status it's really important to get a sodium because there's no way clinically to tell when somebody's hyponatremic none zero so if that's the cause of it it's really critical that you know it and you're not going to figure it out by thinking so you get it but there's no reason ever to get a sodium in somebody who had synal episode their sodium isn't 102 they would not be normal in front of you so there so Syncopy is a transient event which is why arhythmia is the critical thing to think about now there are some biggies that can cause you to pass out for a variety of reasons having to do with a sympathetic tone so you can pass out and then wake up again with a pulmonary ambis for example or some other major C catastrophic event and then wake up but that patient won't be normal they may be awake but they're not normal so all the textbooks I think get Syncopy all wrong because they're writing about all these big things like ectopic pregnancy excuse me ectopic pregnancy doesn't cause Syncopy it causes hypovolemia hypovolemia causes you to fall down maybe and be orthostatic but you're not normal um [Music] so um orthostatic Syncopy is a separate event and we should be able to get a history of that and the most common cause today of orthostatic Syncopy is not ectopic pregnancy or GI bleed what is it drugs meds especially in the elderly numbers three is the most important article in this chapter only because it reminds us of that it reminds us that alpha blockers are given to Old Men all the time because of prostate issues we're going to talk later about why that's probably not a good idea I think it's not a good idea I think it's more harm than good but the reason it's more harm is because it causes Syncopy and diuretics also lots of Syncopy now there again you'll get a history that's different than I'm going around normal and all of a sudden I passed out that's somebody who stood up and they passed out that's different but in any case so let's go back if we really have Syncopy this person was normal they're now they became abnormal they're normal again um that's a special case that's Syncopy that we have to think about and let's think about them for a second again let's go back to timing What's the timing of they were normal then they passed out how fast did it happen it's sudden it's almost always sudden it's not they're getting worse and slowly they go and then they pass out if it's an arhythmia they may have a little bit of a PR Drome you know oh I'm starting to feel funny and then they pass out but it happens very rapidly and then what happens afterwards soon as the AR goes away they wake up so one of the big things is to try to distinguish Syncopy from seizures there is one article in there about that and that's the key seizures do not wake up right away now like everything else in medicine there are exceptions but in general seizures do not wake up there's a post-ictal period period one word of warning of an arhythmia that causes loss of blood for the Rin can cause a seizure so you can have both but for the most part they're pretty easily distinguishable so again I'm not worried about the one who now looks abnormal cuz those we know what to do with I'm worried about the one who now looks absolutely normal and so we have to think about could it have been an arhythmia and the answer is yes it could have been um then we have to think about so what so which are the rhyas that we have to worry about that recur the ones that recur and if they recur could be really harmful so vac is a really important one what are the signs of VTEC there are none okay that's why we have to worry fortunately in all the people who look normal most of them never had VTEC there are a couple other things that are useful that we can look for that we'll talk about in a second but this is how I see the problem which is those guys are sick those guys all look well in there there might be one person I have to worry about how do I identify that person now the old standard approach was take that entire group and be safe and admit them all to the hospital and that obviously is not a great approach because a hospital is not a good place for people and what's more if it was a bad arhythmia two days in the hospital Hospital may not find it and then they go home and then they die cuz they had it so the question now is how do you approach those patients and that's what this chapter talks a little bit about um number four is about predictors of outcome in Syncopy who are the ones who come back sick very few come back sick of the ones who come back sick guess what it's old people with risk for heart disease duh but the interesting thing is that um there are certain types of heart disease that can be bad like um valvular disease which are actually more in young people so throw out what I just said it doesn't matter old people heart disease the really bad ones including vtac are often in young people um number five says we do zillions of tests and number six says they don't give us any useful information especially head C scans if you have something in your head that I'm going to going to find on a CT that caused your Syncopy you are not normal why we do all these head CTS and Syncopy I don't know what we should be thinking about is an arhythmia we should do a good neurologic exam if they're not normal that's entirely different but somebody who's completely they were normal they passed out now they're back to normal that's not a a problem in the brain it's a problem of something that affected the brain and that the one that we have to worry about is an arhythmia so what kinds of things can we do to find the arithm is right so we take a pulse right we evaluate them right in front of us what but they're they're normal so what what are the things that we could what are some Clues we could get it's really pretty easy what's the really important test to do an EKG okay and what do you looking for it an EKG again I want to see something that will tell me trip me off to the idea that wa there might have been a big a rhythmia it's not going on now I'm not going to see it on the monitor but I might see a clue on the EKG what could I see I could see a Long QT that's probably the most important now how long is long there's no answer either you make it very long in which case you're non-sensitive but you are specific is so long that it's really worrisome but it doesn't pick up a lot of the or you make it so short that oh it's a little long that it'll pick up all the people who have an arhythmia but it but it will pick up a billion others so the answer is looks long to me that's the best I can tell you that's what the literature says there is no right answer but if you see an EKG where the there's a Long QT that should trip your mind that maybe this was a ventricular arhythmia so it's something to look for and it's not great it's not going to predict very well but again this is a St we're looking for that life-threatening disease in a very few people if you see a significantly Long QT that's somebody who needs more attention what else can you see on an EKG so there's three articles on Long QT in here what else wpw wpw it's not in this chapter I don't know why because there are articles on it it's an important thing if you see wpw that means they're very very very increased risk for T arhythmia now the usually the T arhythmia are benign it's SVT but every once in a while somebody with wpw gets a not so benign T what's that a aib and particularly apib is a real problem in these people because it goes down the wrong pathway remember apib is the atrium going off like crazy 600 times a minute and the good news is that your AV node blocks it down so you can't go more than 150 times a minute but they have a fast paway that can go 220 and 220 you can pass out not only that you can trip off V vtac and vfib so it's an important one if you see a Delta wave and a short PR and somebody who came with Syncopy that's a big deal those need important referral and then the third one the third thing you see on the AKG is in your chapter and I'm only mostly going to debunk it even though I don't want to completely debunk it it's rugata syndrome and here's why I'm going to debunk it okay the chapter says up to 60% of sudden deaths in Asia may be caused by rugata syndrome that's what it says that's what the literature there's literature out there that says that based on a couple of reports why is that impossible who was here 25 years ago I don't want to point fingers before there was brata syndrome how could it be that it was on every other patient and no one had ever heard of it it's just not possible it it you know it can't be I've been doing this for a long time it's a really weird looking e g if there if were're there every time somebody was passing out um it's hard to imagine that all none of us would ever have known anything about it so there's a good paper here which says why that probably is true and that is number 12 they followed people who had bugata syndrome there were 22 of them now there's two different ways of having brata syndrome it's sort of like having St elevation Mi let's go back from Bata syndrome for a second and talk about a stemi what's a stemi how do you define a stemi that's an important one how do we Define it is elevation greater than 1 mm leaves great so there's there are criteria you could use greater than 1 millim 2 adjacent leads in a pattern blah blah blah that's one definition of stemi there's another definition of stemi which is I walk in the room I see somebody who's going to die and I look at the ukg and there's tombstones on it those are two very different things a stemi a clinical stemi is an obvious event there is no such thing as a clinical stemi who looks n who looks well you walk in the room oh my God doesn't matter what the EKG shows and then the EKG oh yeah look at that it's got these huge tombstones there's another type of stemi which is the patient was fine got sent home something happened and now we're doing a quality improvement review and we go back and look at the EKG and we say look at that look at that there was 1 mm elevation right there how did they miss it but there's a million patients who have 1 mm EST elevation and so using these sort of retrospectoscope definitions to to ascribe blame is a problem that we in emergency medicine have a lot CU people look at our stuff and say how come you miss that but that's a very different thing so bugata syndrome takes also takes different forms it takes the form of there are actually people who die from this but there are also people where you look at the EKG and you say you know I think that's sort of like right bundle what do you think oh yeah let's call it bugata syndrome those are different things so number 12 says we found all these patients with rata syndrome only 10% of them were discovered because they had had a critical arhythmia and when they followed those people who had survived a critical arhythmia 20% of them had a recurrent critical arhythmia in the next couple of years that was a very small group and the risk was high then they had some people who had had a synple episode and somebody said you know I think that's brugata and about 5% of them had a recurrent event over the next few years and then they had people where it was defined purely by EKG somebody did EKG they said oh look at that I think that's verata or some family thing and they followed them and how many of them had an event 1% almost zero less than 1% so I think there's a there we got to keep in mind a clinical event and look at the EKG and oh yeah I noticed this if somebody comes in with real Syncopy and you see real bugata that's important but let's not get over the top about this there's a lot of things where you could look at an EKG you read a billion EKGs you could call this and most of them are meaningless now since we're talking about Syncopy if you get an EKG in Syncopy and you see bugata syndrome true SD elevation in V1 with a right bundle pattern that needs urgent referral cuzz he's already identified himself as having the real deal those are the important things the rest of it says so what do we do so you get an EKG it looks normal are you done well it's sort of like what we talked about head trauma or dizziness or any of these things which is no they still need followup but the good news is they're fine they almost certainly fine the ones who look fine you find nothing they're almost certainly fine now then there are two other things that this mentions none of this has to do with papers there are papers which recommend this like the nice guidelines but there's no evidence for anything I'm about to say which is if there's an obvious reason for their Syncopy that's benign you probably don't have to worry and you probably don't have to do much of anything so they were standing up in the Sun for three hours and then they got weak and then they fell down and now they got had something to drink and they feel better that's probably okay they went in to get their blood drawn and they went they had a little that's no big deal especially if it's a big guy who's always the one who passes out um on the other hand if there's some other thing that really troubles you about the patient it's somebody who has bad coronary disease and they have Syncopy they need closer attention old bad dis underlying disease Etc other than that there's no other Clues and that isn't proven there's no proof of any of that it's just made up but it's probably right so again I think it's re and the nice guidelines you know the English have this bizarre habit of actually trying to think about things and tell us a good approach to it which in America is you know not allowed CU it infringes upon our civil liberties to have somebody tell us what to think so um the nice guideline says a little of what I just said think about are they high risk low risk Etc and um there's a terrible paper about distinguishing cardiac versus vasovagal symy so I'm not going to tell you about it that's number 14 ignore it draw big black lines through it and um oh the last one is syncopy decision rules and one of my soap boxes is decision rules so first of all they shouldn't be called rules they should be called something else right cuz they're not a rule there is no such thing as a rule a rule you must follow so a decision instrument like Nexus is a way to help you think about something but if you think differently for whatever reason you're concerned about a patient ignore it okay so I don't like calling it a rule call it a decision instrument I believe that Nexus is a really good decision instrument for how to decide when a patient doesn't need a neck x-ray I'm pretty sure it works um but I think it works only because it tells you what you already knew because it's obvious nobody actually needed to know that if a patient doesn't hurt on their neck and they're not altered and they're not distracted by something else and they can talk to you and it's fine they're fine I don't think we need to know that we all knew that we just were afraid to do it because you don't want to miss a next thing so the nice thing about studying it was saying you know what turns out it works but it wasn't cuz it was some brilliant thing oh my God if it's a Tuesday and they have four letters in their last name nothing like that stuff we all know decision instruments work when they when they they verify confirm what we really already know but in addition I believe they only work for very simple yes no clinical questions so for example how many ways can you tell me that you've broken your neck think about it for a second how what are the clinical manifestations of breaking your neck it hurts right either it hurts or I can't talk to you I'm altered in some way or other I'm distracted something else is going oh I also could show neurologic findings but other than that how many way what can I how many ways can you tell me you have a broken ankle it hurts when you press on it and you can't put weight on it that's about it that's why the outo ankle rule works now we have a few decision instruments for little things like that yes no questions where you know what if it isn't one of those things don't worry about it how many ways can you tell me you have a having a heart attack Million Ways right you could be altered you could have chest pain you could have shortness of breath you could have abdominal pain you could be nauseated there's a lot of ways that a heart attack expresses itself that's why guess what there are 93 heart attack rules Each of which have three or four versions of themselves and none of them end up working when how many ways can you tell me you have a stroke a zillion ways all these stroke rules and and ABCD 2 scores and ABCD 3 a and 3 I scores anytime a decision instrument has multiple versions of itself it's proving to you that it doesn't work and I'll just tell you the way decision instruments are created cuz I've done this you take a whole bunch of data and you torture it and you find what is the best pattern that comes out out of it and so whatever you do that first time is going to work really well because that's how you created the decision instrument you found the pattern that works very well now the key is to go do it again in a different population and see if it still works if the next time you say you have to say well not exactly that let's just change this one let's call it ABCD 2 means ABCD didn't work in the second one it also means that ABCD 2 didn't work in the original one or that's what they would have used so when you have multiple iterations of the Goldman rule for chest pain it can't be right and of course theoretically conceptually it can't be right either because it's too hard to know to make a rule for P or for heart disease Etc which is why I believe the Wells Criteria the objective Wells Criteria Works a little worse than clinical judgment and in in the United States and Canada 2% of low-risk patients have the disease and in Europe 20% of lowrisk patients have the disease with the same objective score can't be can't be so this says what about the Syncopy rules and guess what it says about them they worked really well when they were first created that's by definition when other people look at them they don't work at all and they have the following characteristic which all medicine tests have which is you can create a version of it that's very sensitive picks up all the people with disease but if you want it to be sensitive it's completely nons specific it picks up everybody they you can also make it much more specific but then it misses everybody they just don't work and I'm not surprised they don't work how could you have a simple rule that's going to tell you all the manifestations of syn of bad syncopy of a rhythmus I don't think it's possible so um that's what this says use judgment and keep I I want to encourage you again to think not only about finding that needle in the Hy stack but also about the harm of over admitting everybody who's old who had anything because you don't want to miss something cuz there is a lot of harm from that and the bad news for us is that if we put ourselves first we just admit everybody cuz we'll never get blamed for that and we will get blamed for the one we missed but if we put the patient first we can't do that and we're supposed to put the patient first