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0:04
A fourth challenge is to determine
who needs aggressive management.
As you can see from
the previous case,
this individual did require
aggressive management
to prevent life-threatening
ventricular
fibrillation from killing her.
0:20
There are various risk
stratification schemes
and algorithms that
have been developed
to assess which individual
is at highest risk for dying.
This doesn't necessarily
mean ventricular
fibrillation as cause for death.
It may be sudden cardiac death.
It may be death from
some other cause.
So in terms of the
emergency department,
this rule, the San Francisco
Syncope Rule, has been used.
The eponym, I think is
the proper term is CHESS,
and that is congestive heart
failure, hematocrit less than 30%,
abnormal ECG, shortness of
breath, and systolic blood
pressure less than
90 on presentation.
The problem is, when you
use a rule like this,
48% of the individuals who came
into the emergency department
with syncope were
considered high risk,
and therefore, clinical
judgment had similar results
in terms of admission and also
in terms of long term outcome.
Therefore, this rule
really did not add much
in terms of how to evaluate
the individual who comes
into the emergency room,
and then the decision
might be to either admit
the patient to rule out
a life-threatening potential
cause for the syncope,
or to let the patient go home.
This is a critical issue in
the emergency department-
what to do with the patient.
More recently, there have
been other approaches
that have been postulated
as being good approaches.
We'll talk a little
about that in a second.
