Syncope and Trauma

 

VBMC TRAUMA CARE SERVICES GUIDELINE

 

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 

 

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.

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.

 

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

Belita, L., Ford, P., & Kirkpatrick, H. (2012). The development of and assessment and intervention falls guide for older hospitalized adults with cardiac conditions. European Journal of Cardiovascular Nursing, 12(3), 302-309.

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.

Gauer, R. L. (2011, September 15). Evaluation of Syncope. American Academy of Family Physicians, 84, 640-650.

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

Summary of the Updated American Geriatrics Society/British Geriatrics Society Clinical Practice Guideline for Prevention of Falls in Older Persons. (2011). The American Geriatrics Society, 59, 148-157.

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.