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<span style="font-size:130%>This page is also available in Dutch: [[eerste evaluatie]]</span> | |||
==Flowchart for the initial evaluation of syncope== | |||
[[File:Seh_flowchart_tloc.jpg|1000px]] | |||
==Goal== | ==Goal== | ||
Recognition/risk stratification of causes for transient loss of consciousness (T-LOC). In particular causes of T-LOC with a high risk for acute cardiac death or causes such as a first epileptic convulsion. <br /> | Recognition/risk stratification of causes for transient loss of consciousness (T-LOC). In particular causes of T-LOC with a high risk for acute cardiac death or causes such as a first epileptic convulsion. <br /> | ||
==Definitions== | ==Definitions== | ||
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==Initial evaluation== | ==Initial evaluation== | ||
Three questions are of interest: | Three questions are of interest: | ||
#Is the patient ABC ( airway, breathing, circulation) stabile at presentation? | #Is the patient ABC ( airway, breathing, circulation) stabile at presentation? | ||
#Is the patient suffering from T-LOC? | #Is the patient suffering from T-LOC? | ||
# | #: A: Was the patient unconscious? <br />This becomes apparent from: | ||
## | ##Amnesia during the unconsciousness | ||
## | ##No response to speech or touch during the unconsciousness | ||
## | ##Abnormal locomotion (falls, myoclonic jerks, lying still, incontinence) | ||
# | #: B: Quick onset and short duration of the unconsciousness? | ||
#Is there an obvious cause and/or is there a high risk for acute cardiac death? | #Is there an obvious cause and/or is there a high risk for acute cardiac death? | ||
For T-LOC the most important diagnostic tool is the | <span style="font-size:110%>For T-LOC the most important diagnostic tool is the medical history. Start history taking with '''open questions.''' <br /> | ||
''What happened? What did you feel? How did you do afterwards?'' </span> | |||
<br /> | |||
<br /> | |||
---- | |||
<span style="font-size:120%>The following elements '''must''' be addressed in any case ('''<span style="color:#ff0000>RED</span>''': risk of acute cardiac death, '''<span style="color:#008000>GREEN</span>''': first epileptic convulsion):</span> | |||
====Circumstances prior to T-LOC==== | ====Circumstances prior to T-LOC==== | ||
*Posture: | *Posture: <span style="color:#ff0000>supine</span>, sitting, standing | ||
*Activity: | *Activity: <span style= "color:#ff0000>during exercise</span>, after exercise, after standing up | ||
*Specific circumstances: micturition, defecation, coughing, swallowing, the sight of blood, (veni)puncture, fear | *Specific circumstances: micturition, defecation, coughing, swallowing, the sight of blood, (veni)puncture, fear | ||
*Predisposing factors: hot environment, fasting | *Predisposing factors: hot environment, fasting | ||
*Specific and rare triggers: | *Specific and rare triggers: <span style="color:#ff0000>a sounding alarm clock, diving</span>, <span style="color:#008000>light flashes</span> | ||
====Start of T-LOC==== | ====Start of T-LOC==== | ||
*Pallor, sweating, abdominal discomfort, vomiting | *Pallor, sweating, abdominal discomfort, vomiting | ||
* | *<span style="color:#FF0000>Palpitations:</span> regular or irregular? Fast or slow? (beware: young people can indicate a sinus tachycardia as “palpitations”, although this is innocent) | ||
* | *<span style="color:#ff0000>Absence of: pallor, nausea, sweating during multiple episodes of T-LOC</span> | ||
* | *<span style="color:#008000>Epileptic aura, focal attack</span> | ||
====During T-LOC (eyewitness)==== | ====During T-LOC (eyewitness)==== | ||
*Duration of T-LOC | *Duration of T-LOC | ||
*Eyes during unconsciousness: open (syncope, epilepsy) or closed (psychogenic) | *Eyes during unconsciousness: open (syncope, epilepsy) or closed (psychogenic) | ||
*Snoring (syncope: during unconsciousness; | *Snoring (syncope: during unconsciousness; <span style="color:#008000>epilepsy: during recovery</span>) | ||
* | *<span style="color:#00FF00><span style="background:#FF0000>Cyanosis</span></span> | ||
* | *Total number of myoclonic jerks (syncope: <10; <span style="color:#008000>epilepsy: >20</span>) | ||
* | *<span style="color:#008000>Lateral tongue bite</span> | ||
====During the end of T-LOC==== | ====During the end of T-LOC==== | ||
*Pallor, sweating, nausea, abdominal discomfort, vomiting | *Pallor, sweating, nausea, abdominal discomfort, vomiting | ||
*Incontinence of urine | *Incontinence of urine or <span style="color:#008000>defecation</span> | ||
* | *<span style="color:#008000>Prolonged confusion</span> (i.e. dysfunctional imprinting; sleeping is not confusion) | ||
* | *<span style="color:#008000>Myalgia</span> | ||
*Rapid spontaneous and complete recovery | |||
====Medical background and history==== | ====Medical background and history==== | ||
* | *<span style="color:#FF0000>History of cardiac disease</span> | ||
* | *<span style="color:#FF0000>Familial acute death < 40 years old with an unknown cause</span> | ||
*Many episodes of T-LOC/long duration of T-LOC (psychogenic) | *Many episodes of T-LOC/long duration of T-LOC (psychogenic) | ||
*Medication (anti diabetic drugs, | *Medication (anti-diabetic drugs, anti-hypertensive drugs, psychiatric medication), intoxications | ||
====Useful information from anamnesis==== | ====Useful information from anamnesis==== | ||
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===Points of interest=== | ===Points of interest=== | ||
*Auscultation of the heart: are indications for structural heart disease present or an arrhythmia present? | *Auscultation of the heart: are indications for structural heart disease present or an arrhythmia present? | ||
*Supine and standing blood pressure and pulse | *Supine and standing blood pressure and pulse: After 5 minutes of supine rest the blood pressure and pulse must be measured at least twice. The patient then rises from supine to standing position. Within 3 minutes of standing the blood pressure and pulse must be measured again. One speaks of orthostatic hypotension if the systolic blood pressure drops with at least 20 mmHg, or the diastolic blood pressure drops with at least 10 mmHg within 3 minutes. If the blood pressure dropped it is wise to continue measuring while standing to see if it will drop further. One must also ask the patient if he/she experiences symptoms during standing. | ||
*Neurological examination: in particular attention for the | *Neurological examination: in particular attention for the <span style="color:#008000>lateral tongue bite </span> | ||
*Trauma (capitis) due to a fall during T-LOC | *Trauma (capitis) due to a fall during T-LOC | ||
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==Policy== | ==Policy== | ||
The policy is determined by the cause of the T-LOC, with the risk of acute cardiac death or the magnitude of the risk for the patients’ health. | The policy is determined by the cause of the T-LOC, with the risk of acute cardiac death or the magnitude of the risk for the patients’ health. | ||
*Category RED (cardiac cause and first convulsion): Acute hospitalization and (rhythm) observation (cardiac) or imaging of the brain (convulsion) | *Category '''<span style="color:#FF0000>RED</span>''' (cardiac cause and first convulsion): Acute hospitalization and (rhythm) observation (cardiac) or imaging of the brain (convulsion) | ||
*Category ORANGE (orthostatic hypotension, very frequent reflex syncope, psychogenic pseudosyncope): policlinical evaluation preferably in a syncope unit | *Category '''<span style="color:#FF8C00>ORANGE</span>''' (orthostatic hypotension, very frequent reflex syncope, psychogenic pseudosyncope): policlinical evaluation preferably in a syncope unit | ||
*Category GREEN (isolated reflex syncope, recognized epilepsy): explain and potentially follow-up by GP or attending physician. | *Category '''<span style="color:#008000>GREEN</span>''' (isolated reflex syncope, recognized epilepsy): explain and potentially follow-up by GP or attending physician. | ||
==References== | ==References== | ||
<Biblio> | <Biblio> |