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Unconsciousness is a state in which a patient is totally unaware of both self and external surroundings, and unable to respond meaningfully to external stimuli. Management of the unconscious trauma patient may be limited in the prehospital setting, as surgical intervention may be necessary. Red flag symptoms - Exertional onset, chest pain, dyspnea, low back pain, palpitations, Detailed account of the event from any available witnesses (eg, whether patient experienced postevent confusion), Patient’s personal or familial medical history of cardiac disease, Measurement of the glucose level by rapid fingerstick, Stool guaiac examination (if appropriate, based on the patient's history), Chest radiography - May serve to identify pneumonia, congestive heart failure (CHF), lung mass, effusion, or widened mediastinum, Computed tomography (CT) of the head (noncontrast) - Has a low diagnostic yield in syncope but may be clinically indicated in patients with new neurologic deficits or in patients with head trauma secondary to syncope, CT of the chest and abdomen - Indicated only in select cases (eg, suspected aortic dissection, ruptured abdominal aortic aneurysm, or pulmonary embolism [PE]), Magnetic resonance imaging (MRI) of the brain and magnetic resonance arteriography (MRA) - May be required in select cases to evaluate vertebrobasilar vasculature, Ventilation-perfusion (V/Q) scanning - Appropriate for suspected PE, Echocardiography - The test of choice for evaluating suspected mechanical cardiac causes of syncope, Normal ECG findings are a good prognostic sign, ECG can be diagnostic for acute myocardial infarction or myocardial ischemia and can provide objective evidence of preexisting cardiac disease or dysrhythmia, Bradycardia, sinus pauses, nonsustained ventricular tachycardia and sustained ventricular tachycardia, and atrioventricular conduction defects are truly diagnostic only when they coincide with symptoms, Loop recorders have a higher diagnostic yield than Holter monitor evaluation, with a marginal cost savings, Ambulatory monitoring appears to have a higher negative than positive diagnostic yield, Head-up tilt-table test - Useful for confirming autonomic dysfunction and can generally be safely arranged on an outpatient basis, Electroencephalography (EEG) - Can be performed at the discretion of a neurologist if seizure is considered a likely alternative diagnosis, Stress test - A cardiac stress test is appropriate for patients in whom cardiac syncope is suspected and who have risk factors for coronary atherosclerosis, Carotid sinus massage (to diagnose carotid sinus syncope), IV access, oxygen administration, and cardiac monitoring, Situational syncope - Patient education regarding the condition, Orthostatic syncope - Patient education; additional therapy in the form of thromboembolic disease (TED) stockings, mineralocorticoids, and other drugs (eg, midodrine); elimination of drugs associated with hypotension; intentional oral fluid consumption, Cardiac arrhythmic syncope - Antiarrhythmic drugs or pacemaker placement, Cardiac mechanical syncope - Beta blockade; if valvular disease is present, surgical correction. The treatment involves avoidance of the precipitant when possible and the initiation of counter maneuvers when anticipated. Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, New York Academy of Medicine, New York Academy of Sciences, Society for Academic Emergency MedicineDisclosure: Nothing to disclose. Except where otherwise stated, drug dosages and recommendations are for the non-pregnant adult who is not breastfeeding. Please subscribe or login to access full text content. Diagnostic efficacy of 24-hour electrocardiographic monitoring for syncope. [Medline]. Birnbaum A, Esses D, Bijur P, Wollowitz A, Gallagher EJ. Loss of effective cardiac activity is generally due to the spontaneous initiation of a nonperfusing arrhythmia, sometimes referred to as a mal… Outpatient management can be used for patients who are at low risk for a cardiac etiology to define a precise cause so that mechanism-specific treatment can be effected. History and physical examination are the most specific and sensitive ways of evaluating syncope. 2015 Dec. 25 (6):391-8. Prevention of Syncope Trial (POST): a randomized, placebo-controlled study of metoprolol in the prevention of vasovagal syncope. Was recovery spontaneous, complete, and without sequelae? Ann Emerg Med. Am J Med. Inpatient admission should be reserved for patients in whom identification of specific immediate risk is needed (eg, those with structural heart disease or a history of ventricular arrhythmia). Supraventricular tachyarrhythmias include supraventricular tachycardia and atrial fibrillation with rapid response. Fortunately, with constant attention to the changing state of consciousness and a willingness to reconsider the situation minute by minute, few mistakes should be made. Sulke N, Sugihara C, Hong P, Patel N, Freemantle N. The benefit of a remotely monitored implantable loop recorder as a first line investigation in unexplained syncope: the EaSyAS II trial. 13(7):499-504. [12]. Micturition, defecation, deglutition, tussive, and carotid sinus syncope are types of situational syncope. 2010 Feb 23. Eddy S Lang, MDCM, CCFP(EM), CSPQ Associate Professor, Senior Researcher, Division of Emergency Medicine, Department of Family Medicine, University of Calgary Faculty of Medicine; Assistant Professor, Department of Family Medicine, McGill University Faculty of Medicine, Canada 2007 Apr. [27]  The analysis of 18 eligible studies determined that the quality and accuracy of both sets of clinical decision rules are limited. [Medline]. Education may have a substantial impact on the prevention of recurrence, especially in situational and orthostatic syncope. [11]. The specific group into which the patient is placed directs the rest of the diagnostic evaluation and treatment. CPR should be performed immediately on any person who has become unconscious and is found to be pulseless. This chapter has presented a physiologic approach to the differential diagnosis and the emergency management of the stuporous and comatose patient. 5(2):80-2. Definition. Autonomic symptoms are predominant. 347(12):878-85. The usefulness of the head-up tilt test in patients with suspected epilepsy. 2014 Nov. 134 (5):e1413-21. [Medline]. Situational syncope and orthostatic syncope also have an excellent prognosis. The approach is based on the belief that after a history and a general physical and neurologic examination, the informed physician can, with reasonable confidence, place the patient into one of four major groups of illnesses that cause coma. Clinical Cytogenetics and Molecular Genetics, Anesthesiology: A Problem-Based Learning Approach, The European Society of Cardiology Textbooks, International Perspectives in Philosophy and Psychiatry, Oxford Specialty Training: Basic Sciences, Oxford Specialty Training: Revision Texts, Oxford Specialty Training: Revision Notes, Plum and Posner's Diagnosis of Stupor and Coma (4 edn), Chapter 1 Pathophysiology of Signs and Symptoms of Coma, Chapter 2 Examination of the Comatose Patient, Chapter 3 Structural Causes of Stupor and Coma, Chapter 4 Specific Causes of Structural Coma, Chapter 5 Multifocal, Diffuse, and Metabolic Brain Diseases Causing Delirium, Stupor, or Coma, Chapter 7 Approach to Management of the Unconscious Patient, Chapter 9 Prognosis in Coma and Related Disorders of Consciousness, Mechanisms Underlying Outcomes, and Ethical Considerations. chronic obstructive pulmonary disease (COPD), Canadian Association of Emergency Physicians. [16]  The percentage of patients with a serious outcome increased across patients divided into quintiles on the basis of peak troponin concentration at 1 month (0%, 9%, 13%, 26%, 70%) and at 1 year (10%, 22%, 26%, 52%, 85%). However, some patients do well after definitive surgical treatment or pacemaker placement. 2005 Nov. 150(5):1065. Rumm Morag, MD, FACEP Member of Salem Emergency Physician Services, PC (SEPS), Salem Hospital 1997 Apr. Sarasin FP, Hanusa BH, Perneger T, Louis-Simonet M, Rajeswaran A, Kapoor WN. Syncope is defined as a transient, self-limited loss of consciousness Framingham data demonstrate a first occurrence rate of 6.2 cases per 1000 patient-years. Medical management will vary according to the original cause of the patient’s condition, but nursing care will be constant. [15], Risk of serious outcome and death in patients with syncope increases with higher peak troponin concentrations, according to a prospective cohort study of 338 patients who had plasma troponin I levels measured with a sensitive assay 12 hours after syncope. Some evidence suggests that combining various risk stratification tools may increase sensitivity and reduce unnecessary admissions. Unconsciousness can be caused by nearly any major illness or injury. Other conditions can mimic syncope. Classically, nausea, diaphoresis, fading or "graying out" of vision, epigastric discomfort, and light-headedness precede syncope by a few minutes. [7] but can occur at any age. Pediatrics. Europace. [10]  Pediatric syncope warrants prompt detailed evaluation. The approach is based on the belief that after a history and a general physical and neurologic examination, the informed physician can, with reasonable confidence, place the patient into one of four major groups of illnesses that cause coma. The deeper you go, the darker the surroundings. Being fully awake, alert, and oriented t… [Medline]. [Medline]. [Medline]. [Medline]. Be sure to scrutinize ECG findings for evidence of Wolff-Parkinson-White syndrome, Brugada syndrome, and long QT syndrome. Martin et al described a risk stratification system that predicted an increased incidence of death at 1 year on the basis of abnormal ECG findings, a history of ventricular arrhythmia, a history of CHF, and age older than 45 years. In non-trauma patients, however, there are no such firm recommendations regarding airway management and the GCS score may be less useful. [Medline]. Presyncopal symptoms reported may include the following: Other information that should be obtained includes the following: A complete physical examination is required, with particular attention to the following: No specific laboratory testing has sufficient power to be absolutely indicated for evaluation of syncope. These stimuli result in autonomic reflexes with a vasodepressor response, ultimately leading to transient cerebral hypotension. Syncope in a patient with poor baseline cardiac function portends a poor prognosis, irrespective of etiology. All Rights Reserved. 1991 Aug. 91(2):179-85. 2012 May 29. Syncope Evaluation in the Emergency Department Study (SEEDS): a multidisciplinary approach to syncope management. [24]. Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical AssociatesDisclosure: Nothing to disclose. 1984 Apr 1. Date of acceptance: July 18 2005. Circulation. The aim of this study was to describe the authors' experience with airway management in unconscious non-trauma patients in the prehospital setting with a physician-manned Mobile Emergency Care Unit (MECU). 125(21):2566-71. 1,2 Unless the cause of unconsciousness is immediately obvious and reversible, both early senior physician and critical care input are required, especially when the prognosis is poor and decisions regarding ceiling of care … Risk factors associated with severe short-term outcomes included abnormal ECG, history of CHF, age older than 65 years, male gender, history of chronic obstructive pulmonary disease (COPD), structural heart disease, presence of trauma, and lack of prodromal symptoms. Syncope: diagnosis and management. Decreased consciousness can affect your ability to remain awake, aware, and oriented. Azizi Malamiri R, Momen AA, Nikkhah A, et al. Acad Emerg Med. [1] with an inability to maintain postural tone that is followed by spontaneous recovery. You could not be signed in, please check and try again. [16], Decision rules may assist in identifying patients who are at risk. [Medline]. The Evaluation of Guidelines in SYncope Study 2 (EGSYS 2) prospectively followed nearly 400 patients at 1 month and 2 years. A person who is unconscious and unable to respond to the spoken words can often hear what is spoken. Middlekauff et al studied 491 patients with NYHA functional class III or IV disease and noted that, regardless of the cause, 45% of those with syncope died within 1 year, whereas 12% of those without syncope died during the same interval. Low flow states, such as those associated with advanced cardiomyopathy, congestive heart failure (CHF) , and valvular insufficiency, may result in hypotension and cause transient global cerebral hypoperfusion. In elderly patients, 45% of these cases are related to medications. Soteriades ES, Evans JC, Larson MG, et al. Unconscious Patient Care & Communication Skills required in Critical Care 1Prof. betapace-af-sotalol-342365 Acad Emerg Med. Usability of the head upright tilt test for differentiating between syncopal and seizure-like events in children. Walsh K, Hoffmayer K, Hamdan MH. The ROSE (risk stratification of syncope in the emergency department) study. Ungar A, Mussi C, Nicosia F, et al. Ann Emerg Med. Was loss of consciousness with rapid onset and short duration? Prior faintness, dizziness, or light-headedness (70% of cases of true syncope), Prior vertigo, weakness, diaphoresis, epigastric discomfort, nausea, blurred or faded vision, pallor, or paresthesias. Nursing 1st year 2. Specific pathology includes aortic stenosis, hypertrophic obstructive cardiomyopathy, mitral stenosis, pulmonary stenosis, pulmonary embolus, left atrial myxoma, and pericardial tamponade. J Pediatr. [Medline]. [Medline]. David A Peak, MD Associate Residency Director of Harvard Affiliated Emergency Medicine Residency; Attending Physician, Massachusetts General Hospital; Assistant Professor, Harvard Medical School These measures, along with 12-lead electrocardiography (ECG), were the only current level A recommendations listed in the 2007 American College of Emergency Physicians (ACEP) Clinical Policy on Syncope. Patients with cardiac syncope may be significantly restricted in their daily activities, and the occurrence of syncope may be a symptom of their underlying disease progression. [13], Patients with cardiac syncope appear to do worse than patients with noncardiac syncope. In order to achieve the best possible outcomes while decreasing the risk of undetected injuries, the management of trauma patients requires a highly systematic approach. Dial 999 to request an ambulance if the person is unconscious or unable to get out of the affected area. Pediatr Emerg Care. Syncope is relatively uncommon in pediatric populations. All material on this website is protected by copyright, Copyright © 1994-2020 by WebMD LLC. [1] Brain parenchyma depends on adequate blood flow to provide a constant supply of glucose, the primary metabolic substrate. [23]  The mortality was 0.7%, and 5.4% of patients were readmitted or experienced major therapeutic intervention. Risk stratification of patients with syncope. [Medline]. Management of unconscious patient By: Nidhi Maurya Era’s college of nursing M.Sc. Measurements with both scales were obtained 1 min before, during, and 20 min after nursing procedures in both conscious (n.41) and unconscious (n.60) patients; furthermore, VAS was recorded when possible in conscious patients only. Limited evidence suggests that polydipsia may reduce recurrences. Is ambulatory monitoring for "community-acquired" syncope economically attractive? The authors concluded that further study was needed. 29(4):459-66. Syncope in children and adolescents. 53(8):1013-7. Am J Cardiol. Prospective evaluation of syncope. Syncope of unknown etiology generally has a favorable prognosis, with 1-year follow-up data showing a low incidence of sudden death (2%), a 20% chance of recurrent syncope, and a 78% remission rate. [Medline]. [Medline]. 2016 Jun. History and physical examination are the most specific and sensitive ways of evaluating syncope. [Medline]. 1993 Jan. 21(1):110-6. 2020. 49(4):431-44. Conversely, the presence of hemiplegia or other focal signs does not rule out metabolic disease, especially hypoglycemia. These causes tend to be more benign and do not predict poor outcomes. Patients who present to the ED with syncope should be cautioned to avoid tall ledges and instructed not to drive. Quinn JV, Stiell IG, McDermott DA, Sellers KL, Kohn MA, Wells GA. Derivation of the San Francisco Syncope Rule to predict patients with short-term serious outcomes. This type of syncope is generally unrelated to posture and can occur during lying, sitting, or standing. Tests may not be necessary and can be tailored to any signs or symptoms that raise concern for a specific underlying illness. Assessment of the unconscious patient The first priority is to ensure safety before approaching the patient. The unconscious patient is completely dependent on the nurse to manage all their activities of daily living and to monitor their vital functions. We calculated criterion and discriminant validity to both scales (Wilcoxon, Spearman rank correlation coefficients). A clinically significant defect in any one of these systems or subclinical defects in several of them may cause syncope. The term syncope excludes seizures, coma, shock, or other states of altered consciousness. If you survive sudden cardiac arrest, your doctor will try to learn what caused it to help prevent future episodes. Obtaining an initial electrocardiogram (ECG) is mandatory if any of these causes are possible for the differential diagnosis. These measures, along with 12-lead electrocardiography (ECG), were the only current level A recommendations listed in the 2007 American College of Emergency Physicians (ACEP) Clinical Policy on Syncope. 2010 Oct. 56(4):362-373.e1. Although many etiologies for syncope are recognized, categorization into reflex (neurally mediated), orthostatic, and cardiac (cardiovascular) may be helpful during the initial evaluation. Seizure. It is unclear whether hospital inpatient admission of asymptomatic patients after syncope affects outcomes. J Am Coll Cardiol. Syncope due to orthostatic hypotension can occur through several mechanisms. Ann Emerg Med. Secondary autonomic insufficiency can be due to diabetes, uremia, or spinal injury. Protect the airway of the unconscious patient. Nursing the unconscious patient NS309 Geraghty M (2005) Nursing the unconscious patient. Recurrent falls due to syncope can result in lacerations, orthopedic injuries, and intracranial trauma. 18 (6):912-8. Drugs, encoded search term (Syncope) and Syncope, Malignant Arrhythmia and Cardiac Arrest in the Operating Room, Arrhythmogenic Right Ventricular Dysplasia (ARVD), Atrioventricular Nodal Reentry Tachycardia, A Review of ACR Convergence Abstracts on Systemic Lupus Erythematosus, Higher Risk of Falls/Fractures With Androgen Receptor Inhibitors, Famous Patients: From Goethe to Beethoven, Marley to Bogart, Chili Pepper Consumption Linked to Better Midlife Survival, Pesco-Mediterranean Diet, Fasting 'Ideal' to Reduce CVD, SAMSON Pins Most Muscle Pain Experienced With Statins on the Nocebo Effect, Proinflammatory Dietary Pattern Linked to Higher CV Risk, A Barely Responsive Woman Dropped at the ED With a Note, First-line Ablation Bests Drugs for AFib inTwo RCTs, New Model Quantifies Cardiac Arrest Risk in Brugada Syndrome. [Medline]. Calkins H, Shyr Y, Frumin H, Schork A, Morady F. The value of the clinical history in the differentiation of syncope due to ventricular tachycardia, atrioventricular block, and neurocardiogenic syncope. 2003 Dec. 10(12):1312-7. [Guideline] Huff JS, Decker WW, Quinn JV, et al. 2004 Sep. 44(3):215-21. In the United States, the leading cause of death in young adults is trauma. Share cases and questions with Physicians on Medscape consult. The unconscious patient is unable to ensure their own safety and in deeper levels of coma may be unable to protect their own airway. Found the same time distinguishing cardiac syncope are types of situational syncope and syncope. In patients with syncope should be cautioned to avoid tall ledges and instructed not to drive as well as.. Can occur through several mechanisms and atrial fibrillation with rapid onset and short duration SE Neuman... 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