COLLAPSE ? CAUSE

WHY IS THIS AN IMPORTANT TOPIC TO MASTER?

One of the great skills in EM is the ability to risk stratify patients accurately and to formulate an informed management plans.

It is also important to enable the patient to make an informed decision in understanding proposed investigations, their risks and benefits and consenting to further investigation.

A CASESo lets think of a case to start with

60 years man

Comes in following a collapse at the shops, an ambulance is called and the paramedics bring him to your ED. On arrival he’s alert and orientated

GCS 15

Pulse 80 bpm

BP 120/80

RR 16

SpO2 on air 99%

Temp 36.2

BM 5.7

He’s been well for the past few days, no history pointing you towards a diagnosis, no significant PMH. No meds and his examination is completely unremarkable,

WHAT WOULD YOU DO WITH THIS PATIENT?

THE PAPER

By Quinn J et al.

Annals of Emergency Medicine 2006

‘Prospective validation of the San Francisco Syncope Rule to predict patients with serious outcomes’

ABOUT THE SANFRANCISCO SUNCOPE RULE

The rule that they’re attempting to validate is the ruel they produced to risk stratify patients into low and high risk of morbidity and mortality. It is also referred to as the CHESS score, which stands for…..

• C – ongetsive cardiac failure

• H – ct < 30%

• E – CG abnormality – any

• S – ystolic BP < 90 mmHg

• S – hortness of breath in the history

INCLUSION CRITERIA

Patients with a symptom of syncope

Syncope was defined as a ‘transient loss of consciousness with return to baseline neurological function

Prospective study between 2002-2004

EXCLUSION CRITERIA

Trauma-associated LOC

Alcohol/drug involvement

Definite seizure

OUTCOME MEASURES30 follow up after the index visit to the ED and determined short term outcomes that would mandate emergency admission

Short term serious outcomes

• Death• MI• Arrhythmia • PE• Stroke• SAH• Significant haemorrhage/anaemia requiring transfusion• Any condition causing/likley to cause a return visit• Procedural intervention to treat a related cause of syncope

ACUTE INTERVENTIONS DEFINED AS…..

A procedure required to treat a condition related to the patient’s syncope

• Dialysis• Pacemaker insertion• Surgery for valvular heart disease• Baloon pump insertion• Vasopressor use• Surgery for an AAA/ruptured spleen/ectopic pregnancy• Endoscopy for varices

RESULTSInformation gathered for 767 visits

Average age of 61 years, 13.7 % of patients were deemed to have had a serious outcome

San Francisco rule classified 52% of patients as high risk

If the rule had been used to determine admission/discharge decisions it would have decreased admissions by 7%

The study was powered to determine sensitivity and specificity with 95 % Cis within 10% (which it just failed to achieve with the sensitivity).

The rule was 90% sensitive (95 % CI 89-100%) and 56 % specific (95% CI 52-60%) in predicting serious outcomes

REFERENCES

Quinn J, McDermott D, Stiell I, Kohn M, Wells G. Prospective validation of the San Francisco Syncope Rule to predict patients with serious outcomes. Ann Emerg Med. 2006;47(5):448-54.