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FACP. Colegio de médicos de Tarragona Nº 4305520 / fgcapriles@gmail.com




Saturday, December 19, 2015

Síncope: evaluación y manejo

emDocs - September 10, 2015 - Author: Cassella C. Edited by: Koyfman A; Long B.
Definition: Transient loss of consciousness with spontaneous recovery
..."In patient’s presenting with syncope, the most pertinent question in management is, does the patient need an inpatient admission or observation for additional investigation?
Low risk patients, as identified by ACEP Clinical policy,6 may be considered for discharge with prompt outpatient follow-up. In a RCT by Sun et al,23 intermediate risk patients were randomized to inpatient admission versus observation unit. Intermediate patients were those older than 50 years with no high or low risk features (see table below). The study found intermediate risk patients could undergo an observation period with similar serious outcomes to admission at 40 days. The observation period consisted of at least 12 hours of cardiac monitoring, 2 serial troponins, and an echocardiogram for those with a murmur or no echo within 6 months.
In determining high-risk patients, clinical decision rules alone are not reliable for clinical practice.7, 8 A 2014 meta-analysis by Costantino et al compared the OESIL, SFSR, and EGSYS prediction tools with clinical judgment. The paper found clinical judgment had a sensitivity of 95% versus clinical decision rules sensitivity of 63-78% in predicting serious outcomes at 10 days. This data does not support the use of only clinical judgment, but sheds light on the inconsistency of clinical decision rules. However, clinical decision rules, medical society guidelines, and clinical judgment can help direct the emergency physician to high-risk patients requiring admission..."