My mini rant on syncope
Curious to know what your thoughts are on my mini syncope rant. Since there's so many that come through ED and then spend a couple days on the ward. (PREFACE: I'm not even a reg - so these are just some musings. Not me thinking I know better necessarily)
Loss of consciousness is immediately labelled syncope. Passing out does NOT instantly mean syncope.
LOC on the realm of ~5 minutes .... is that even still syncope?? Thought the definition of syncope necessitates rapid onset and relief.
The insane differential and pointless investigations. Seriously, without any neurological changes why am I ordering an MRI - Brain for EVERY syncope to rule out stroke !? I get an initial non-contrast CT brain. But Stroke/TIA tends to be part of the differential a lot. Also (more of an academic pet peeve) but you can't say someone has syncope and then include hypoglycaemia on the differential bc if the patient lost consciousness due to hypoglycaemia it's not a matter of transient global cerebral hypoperfusion is it? It's an issue with glucose availability and metabolic cause of LOC. I hate how they get immediately labelled as syncope.
Re: MRI-B and ruling out stroke
Fair enough if they had some sort of lateralising/focal neurology on history or on examination when in the ED. But for EVERYONE (in reailty - more than 50%) (??) cmon... Also thought reduced consciousness in cases of stroke is rare (brainstem stroke or herniation). what is the yield in these MRIs?
Polypharmacy.... I usually see a trend of antihypertensives discontinued, only to eventually be restarted in a majority of cases once we fluid resus them if they had some orthostatic hypotension. That's fine but what's the benefit in continuing on an ACE for example in an elderly very comorbid patient. So many more medication classes could genuinely be contributing especially in a frail patient, and it's just sad to see these nursing home residents come in for the same thing. I'm sure it's hard for that 1-2 GP looking after hundreds of residents.
On the fence about repeated blood tests once they hit the ward. I have seen many ... maybe the K is like 3.2. Sure, but no ECG changes. Or some long standing iron deficiency anaemia. Seriously, no zebras here - chronic, stable disease. They hit the wards and then we give them some very small amount of fluid, some oral electrolytes (which they will continue taking on discharge btw for a few days), maybe an iron infusion sometimes. Point is, treatment that is very fit for an outpatient setting. WHY am I wasting money on daily blood tests while I sort out their disposition? A daily FBC and UEC?
Curious to know all your thoughts, and to see if this trend is true across the country.