Syncope: finding the cause of the drop 2

Published on February 11, 2015 Reviewed on January 10, 2021   26 min

A selection of talks on Clinical Practice

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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.
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.