SYNCOPE Syncope Evaluation The following pathway presents a possible diagnostic sequence based on the preceding information. Etiologies: P-A-S-S O-U-T (mnemonic) H*P*, EKG, Labs: (CBC, Lytes, BG, BUN/Cr. Ca+, Sao2) *H&P should include BP (lying & standing BP's) P ressure (hypotensive causes) O utput (cardiac)/O2 (hypoxia) A rrhythmias U nusual causes S eizures T ransient Ischemic Attacks & If: S ugar (hypo/hyperglycemia) Strokes, CNS dz's Structural heart disease** or ****************************************************** Cardiac sx &/or risk P ressure or Abn. EKG** If YES to any INPATIENT for or of the -MI r/o 1) Vasovagal Unsecure Home preceding -Cardiac Monitor 2) Orthostatic Hypotension Environ. consider -If Seizure sx do EEG Causes a) Volume Loss d) Primary Autonomic dz.* or initial -If Cardiac output sx's b) Medications e) Secondary Autonomic dz.# Seizure INPATIENT do Echo c) Situational ** f) Adrenal Insufficiency or management -If neuro sx's or signs Acute neuro sx. do CT or A rrhythmias - Bradyarrhythmias, Tachyarrhythmia's (SVT, NSVT, A.F.), Significant injury pacemaker malfunctions ** Structural heart S eizures disease = Negative w/u S ugar (hypo/hyperglycemia) CAD, CHF, Valcular disease, O utput (cardiac)/O2 (hypoxia) cong. heart disease

**Abnormal EKG: old NO Structural heart dz? MI, or Abn. EKG? or Cardiac CARDIAC PULMONARY (O2) BBB, arrhythmias, risk or sx? -A.S., P.S., M.S. -P.E. conduction YES -IHSS -Pulm. HTN syst. disease -Cardiomyopathies: -COPD exacerbation -Atrial Myxoma -C.O. poisoning If none of the above -Cardiac Tamponade

-Aortic Dissection -M.I. -CHF

U nusual causes Consider OUTPATIENT (if History Stress Test home support system suspicio (Exercise stress echo, Causes:-Anxiety -Major depressive disorder secure) us or -Panic disorder -Hyperventilation syndrome for Pharmacologic stress -Somatization disorder arrhyth test) mia?

T ransient Ischemic Attacks & Strokes (and other CNS causes)

NO YES Negative Causes: -CVA's -Subclavian steal -TIA's (vertebro-basilar) -Basilar artery migraine -Subarachnoid -CNS mass effect:

hemorrhage -Subdural hematoma (tumor, edema, AVM) Complete the "PASS OUT" Cardiology & EPS? ********************************************************* evaluation *Primary ANS dz:Idiopathic, Multi-System Atrophy(Shy-Dragger), Parkin's dz #Secondary ANS dz:Neuropathic (DM, amyloid, alcoholism, auto-

immune Cancer, B12 def., porphyria, renal failure) **Situational: micturition, postprandial, cough, carotid sinus sensitivity defecation, laughing & postprandial evv9/7/08 Negative Negative

Tilt Table? Negative (but still suspect arrthythmia)

Event Monitor (for brady-arrhythmias)