Syncope / 20XX
Aim:
· Early identification and treatment of life threatening causes of syncope e.g. arrhythmia, hypovolaemia & escalation of care for patients at risk.
· Early initiation of treatment / clinical care and symptom management within benchmark time.
Assessment Criteria: On assessment the patient may have one or more of the following signs / symptoms:
O History of faint / brief LOC / O Diaphoresis / O Nausea or vomiting
O Light headedness / weakness / O Confusion / anxiety / O Blurry or dim vision
Escalation Criteria: Immediate life-threatening presentations that require escalation and referral to a Senior Medical Officer (SMO):
O Cardiac Arrhythmia / O Hypotension & tachycardia / O Suspected Ectopic pregnancy
O Suspected Pulmonary Embolism / O Haematemasis / O Suspected Stroke / TIA
O Blood in Stool - Malaena / O Abdominal distension / rigidity / O Seizures / Postictal
Primary Survey:
· Airway: patency / · Breathing: resp rate, accessory muscle use, air entry, SpO2.
· Circulation: perfusion, BP, heart rate, temperature / · Disability: GCS, pupils, limb strength
Notify CNUM and SMO if any of the following red flags is identified from Primary Survey and Between the Flags criteria.1
O Airway - at risk
· Partial / full obstruction / O Breathing - Respiratory distress
· RR < 5 or >30 /min
· SpO2 < 90% / O Circulation – shock / altered perfusion
· HR < 40bpm or > 140bpm
· BP < 90mmHg or > 200 mmHg
O Disability - decreased conscious level
· GCS ≤ 14 or any fall in GCS by 2 points / O Exposure
· Temperature < 35.5°C or > 38.5°C
· BGL < 3mmol/L or > 20mmol/L / · Capillary return > 2 sec
· Postural drop > 20mmHg
History:
· Presenting complaint· Allergies
· Medications: Anticoagulant Therapy, Anti-hypertensives, Diabetic meds, Analgesics, Inhalers, Chemotherapy, Non-prescription meds, Any recent change to meds
· Past medical past surgical history relevant
· Last ate / drank & last menstrual period (LMP)
· Events and environment leading to presentation i.e. Red flags – palpitations, syncope with exercise, chest pain, palpitations, back pain, haematemesis / melaena before the syncopal episode.
· Pain Assessment / Score: PQRST (Palliating/ provoking factors, Quality, Region/radiation, Severity, Time onset)
· Associated signs / symptoms: chest pain, palpitations, low blood pressure, dizziness, lightheadedness, any associated injuries
Systems Assessment:
· Focused cardiac & neurological assessment: Inspection / Palpation / Auscultation· Identify location of pain i.e. look for any signs of injury or illness.
· BP should be checked in the upper extremity bilaterally in supine and standing positions.
· Pulse rate and rhythm are useful in the diagnosis of arrhythmias and Pulmonary Embolism.
· Cardiac auscultation may reveal murmurs of aortic stenosis and pulmonary arterial hypertension.
· Presence of sensory, motor, speech, and vision deficits suggests an underlying neurological problem.
Notify CNUM and SMO if any of the following red flags is identified from History or Systems Assessment.
O Chest pain / palpitations / O Elderly > 65years / O Severe headache
O Acute Coronary Syndrome (ACS) / O Anticoagulant therapy / O Postural drop > 20mmHg
O Decreased LOC / O Acute confusion / agitation / O Trauma head / neck
Investigations / Diagnostics:
Bedside: / Laboratory / Radiology:
· BGL: If < 3mmol/L or > 20mmol/L notify SMO O / · / Pathology: Refer to local nurse initiated STOP
· ECG: look for Arrhythmia , AMI O / Quantitative ßHCG if urine positive for same
· Urinalysis / MSU & βHCG / Group and Hold (if bleeding suspected)
· Postural Blood Pressure (3mins > 20mmHg) / Blood Cultures (if Temp≥38.5 or ≤35°C)
· / Radiology: Refer to local nurse initiated STOP
Nursing Interventions / Management Plan:
Resuscitation / Stabilisation: / Symptomatic Treatment:
· Oxygen therapy & cardiac monitor [as indicated] / · Antiemetic: as per local nurse initiated standing order
· IV Cannulation (consider large bore i.e. 16-18gauge) / · Analgesia: as per local nurse initiated standing order
· IV Fluids: Sodium Chloride 0.9% 1 L IV stat versus over 8 hours (discuss with SMO) / · IV Fluids: as per local nurse initiated standing order
Supportive Treatment:
· Nil By Mouth (NBM) / · Fluid Balance Chart (FBC)
· Monitor vital signs as clinically indicated
(BP, HR, T, RR, SpO2) / · Monitor pain assessment / score
· Monitor neurological status GCS hourly
Practice Tips / Hints:
· When a patient presents to the emergency department, it is important to correctly differentiate benign neurocardiogenic causes of syncope from life-threatening causes of syncope. A detailed account of the event should be taken from the patient / family or bystander 2
· Precipitating factors, signs and symptoms, patient's position at the time of event, duration of syncope, recovery time, and family history are all important points to be considered 2.
· Red flag symptoms of potentially life-threatening causes of syncope are syncope with exercise, chest pain, palpitations, back pain, haematemesis, and melaena before the syncopal episode. Palpitations before loss of consciousness are a significant predictor of a cardiac cause of syncope 2.
· Situational syncope with activities including coughing, swallowing, micturition, and defecation suggests that the cause is neurocardiogenic or vasovagal 2.
· Neurocardiogenic syncope is frequently recurrent and precipitated by fatigue, hot environment, severe pain, starvation, alcohol consumption, emotional or stressful situations, and prolonged standing. The patient is usually in the standing position and complains of symptoms of feeling weak, nausea, diaphoresis, palpitations, and blurring of vision 2.
· Patients with exertional syncope and positive family history of syncope or sudden cardiac death are at increased risk of sudden death and need to be evaluated further to rule out cardiac causes of syncope such as prolonged QT syndrome 2.
Reference: http://bestpractice.bmj.com.acs.hcn.com.au/best-practice/monograph/248/diagnosis/step-by-step.html
Further Reading / References:
1. SESLHD Patient with Acute Condition for Escalation (PACE): Management of the Deteriorating Adult and Maternity Inpatient SESLHD/PR283. http://www.seslhd.health.nsw.gov.au/Policies_Procedures_Guidelines/Clinical/Other/SESLHDPR283-PACE-MgtOfTheDeterioratingAdultMaternityInpatient.pdf
2. BMJ Best Practice - Assessment of Syncope (CIAP) http://bestpractice.bmj.com.acs.hcn.com.au/best-practice/monograph/248/diagnosis/step-by-step.html
3. Huff, J.S; Decker W; Quinn J. et al (2007) Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department with Syncope. Annuals of Emergency Medicine (49) 431-444. http://www.nursingconsult.com/nursing/guidelines/article?guideline_id=189227&parentpage=search
Acknowledgements: SESLHD Adult Emergency Nurse Protocols were developed & adapted with permission from:
· Murphy, M (2007) Emergency Department Toolkits. Westmead Hospital, SWAHS
· Hodge, A (2011) Emergency Department, Clinical Pathways. Prince of Wales Hospital SESLHD.
Revision & Approval History
Date / Revision No. / Author and Approval
Syncope – Adult Emergency Nurse Protocol Page 2