Sarin, Ritu MD; Habboushe, Joseph MD, MBA
A 29-year-old woman waiting to be seen in the emergency department went to the bathroom to provide a urine specimen. While on the toilet, she vomited and then had a syncopal episode. Her husband prevented her from hitting her head when she fell off the toilet, and he called for help as she started to wake up.
The nursing staff, attending, and resident came to the bathroom to help the patient onto a stretcher. Initial vital signs showed the patient was tachycardic at 101 bpm, normotensive at 123/99 mm Hg, and afebrile at 98°F, with a respiratory rate of 22 bpm and an oxygen saturation of 100% on room air.
The common standard differential for initially assessing a patient with syncope consists of arrhythmia, hypoglycemia, anemia, vasovagal syndrome, and orthostatic hypotension. It is helpful to organize a diagnostic approach of dangerous versus benign causes, as well as painful versus painless causes, however, when dealing with an unstable patient with syncope.
Less commonly remembered are the “bad and painful” causes:
* Headache and syncope: subarachnoid hemorrhage.
* Chest pain and syncope: pulmonary embolism or aortic dissection.
* Abdominal pain and syncope: ruptured ectopic or AAA.
The Basics of Emergency Medicine: A Chief Complaint-Based Guide includes an approach to syncope and pre-syncope (see table) that uses a differential-focused workup for the dangerous causes of syncope.
A brief initial assessment of the patient indicated she had presented to the ED because of intense nonradiating lower abdominal pain for four hours. The pain had progressively worsened, and was aggravated by movement. She denied vaginal bleeding or discharge, diarrhea, dysuria, hematuria, fever, chills, dizziness, headache, chest pain, and shortness of breath. The patient noted similar pain a few weeks prior for which she was seen in the ED. She denied any significant past medical history, and did not know her pregnancy status.
The patient appeared uncomfortable and pale. Her pupils were equal and reactive, conjunctiva pink, and scelra clear. Her neck was supple without JVD, and she was tachycardic. Breath sounds were clear and equal bilaterally.
Her abdomen was diffusely tender, more so in the lower than upper quadrants, with rebound and guarding. She had no CVA tenderness. Her lower extremities were nontender without edema and had normal distal pulses. Neurologically she was intact without gross deficits.
Diagnosis and Treatment
The patient was placed on a cardiac monitor. The initial FAST ultrasound exam, performed with the patient lying supine, was negative for free fluid. Given a high pretest probability for a ruptured ectopic pregnancy in this patient with abdominal pain and syncope, the FAST ultrasound exam was repeated after the patient was put in the Trendelenburg position, revealing free fluid in Morison's pouch. (See ultrasound.)
Laboratory tests including CBC, BMP, type and screen, and beta-hCG were ordered, and two large-bore intravenous lines were placed. The patient had just urinated and was too unstable to wait for her to urinate again, so a bedside pregnancy test was run with whole blood. (See photo.) Recently described as a rapid way to test pregnancy at the bedside, studies have shown that whole blood point-of-care testing with standard urine pregnancy tests have accuracy close to that of urine, with a 95.8% sensitivity and 100% specificity, as long as a full five minutes elapse before reading the test. (J Emerg Med 2012;43:478; Ann Emerg Med 2011;29:840.)
The patient was bolused with two liters of normal saline and given intravenous morphine and ondansetron for symptom relief. Given the findings of a positive FAST exam and positive whole blood point-of-care pregnancy test, a diagnosis of a ruptured ectopic pregnancy was presumed. OB-Gyn was emergently consulted, and the patient was prepped for the operating room.
The patient denied any past medical or surgical history, medication use, smoking, alcohol use, or illicit drug use. She was sexually active with her husband, but did not use oral contraceptives, an IUD, or condoms. The patient's os was closed on pelvic exam and no blood or abnormal discharge was present, but she was tender to palpation diffusely in the adnexa and over the cervix.
A transvaginal ultrasound was performed by OB-Gyn while awaiting transport to the OR that revealed heterogeneous material in the cul-de-sac and left adnexa, confirming the diagnosis of ruptured ectopic.
Laparoscopic findings in the operating room showed the left fimbriated portion of Fallopian tube had ruptured. A clot approximately 1600 mL was visualized in the abdomen, including an organized clot in the cul-de-sac on the left. A partial left salpingectomy was performed, and the patient recovered without complications. Pathology did not show any gross fetal parts, but did show clotted blood, papilliferous tissue, and fallopian tube
Syncope as a Chief Complaint
Syncope or near-syncope accounts for one to two percent of ED visits annually, resulting in six percent of hospital admissions per year. The differential for syncope is extensive, with estimates of 10 percent being of cardiac origin, 21 percent vasovagal, nine percent related to orthostatic hypotension, nine percent neurological, including seizures, and up to 40 percent for unknown reasons. Patients with syncope and neurological or cardiac causes have a significant increase in mortality; patients with unknown causes have an increased risk of death of 30 percent. (Tintinalli's Emergency Medicine, 7th edition; New York: McGraw-Hill, 2011 [Ch. 56].)
Multiple clinical guidelines have been developed to help the emergency physician approach this large population of patients where missing important risk factors can have fatal consequences for the patient. The most commonly referenced decision rule in current literature is the San Francisco Syncope Rule, which can be found on MDCalc.com, a website designed by EMN's Emergentology author Graham Walker, MD. (Ann Emerg Med 2004;43:224; Ann Emerg Med 2006;47:448.) This rule was developed to assess adverse outcomes in patients seven and 30 days after syncope. The derivation of a clinical rule identified the several predictors of significant adverse events, primarily arrhythmias and anemia, using the acronym CHESS:
C: History of CHF.
H: Hematocrit below 30.
E: Abnormal ECG findings.
S: Shortness of breath on history or exam.
S: Systolic blood pressure below 90.
These criteria have not been well validated in the literature, but they are often referenced and used as a guideline by practitioners when approaching possible cardiac causes of syncope. (Ann Emerg Med 2008;52:151.) They do not, however, address many of the more difficult-to-remember differentials for syncope, including the bad and painful.
More recently developed, the Boston Syncope Criteria used a larger list of factors to identify patients at risk for critical outcomes. (J Emerg Med 2007;33:233 and 2012;42:345.) Patients are considered at risk if they meet any of the following criteria:
* Signs and symptoms of acute coronary syndrome.
* Signs of conduction disease.
* Worrisome cardiac history.
* Valvular heart disease by history or physical examination.
* Family history of sudden death.
* Persistent abnormal vital signs in the ED.
* Volume depletion.
* Primary central nervous system event.
These criteria are more expansive than the San Francisco Syncope Rule and likely to assist in identifying patients at risk for adverse outcomes, but they have yet to be externally validated.
Syncope, in common practice and supported by ACEP guidelines, is commonly approached with an initial workup consisting of an ECG, cardiac monitoring, bedside glucose testing, urine pregnancy test, and CBC, with further testing focused by history and physical. (Ann Emerg Med 2007;49:431.) The initial workup is fairly standard, but it only addresses the commonly remembered differential for syncope including cardiac causes, hypoglycemia, vasovagal, orthostatic hypotension, and anemia.
The differential can first be divided into the dangerous and less-dangerous causes of syncope. The dangerous differential list can be classified as painless or painful. Dangerous painless causes of syncope include cardiac arrhythmias, new valvular disease, myocardial infarction, hypoglycemia, and anemia. Cardiac causes that are often overlooked include Brugada syndrome, prolonged QT, Wolff-Parkinson-White syndrome, and signs of hypertrophic cardiomyopathy. (Am J Emerg Med 2007;25(6):688.) The history and physical exam should be focused on this differential list.
The dangerous and painful causes of syncope are often overlooked by inexperienced clinicians, and include subarachnoid hemorrhage (headache), pulmonary embolism (chest pain), aortic dissection (chest pain), ruptured ectopic pregnancy (abdominal pain), and ruptured abdominal aortic aneurysm (abdominal pain).
These diagnoses are much less common than the dangerous and painless causes, but the patients are often much more critically ill. Getting into the habit of even briefly considering these diagnoses on all syncope patients may help increase the clinician's diagnostic accuracy for these high-mortality diseases.
The dangerous and painful cause of syncope in this case was a ruptured ectopic pregnancy. Consideration of ruptured ectopic pregnancy in a young woman with syncope and abdominal pain not only led to a FAST ultrasound very early in the patient's course of treatment, it also compelled repeating the ultrasound in the Trendelenburg position. Early consideration of a ruptured ectopic pregnancy also resulted in diagnosing the pregnancy with a drop of blood on a urine pregnancy test, leading to the correct diagnosis and timely treatment.
Ectopic pregnancy is relatively common, occurring in one in 3,000 pregnancies to one in 30,000. The history and exam tend to point the physician in the right direction, but studies have shown that women are wrong 10 percent of the time when they say there is absolutely no way they can be pregnant. (Ann Emerg Med 1989;18:48.)
Multiple risk factors exist, including a history of PID, infertility for more than two years, tubal surgery or ligation, prior ectopic pregnancy, and IUD placement. Data show that 50 percent of women with ectopic pregnancy have one or more risk factors, but 25 percent of patients with an intrauterine pregnancy and threatened abortion also have one or more of these risk factors.
Most patients will present with lower abdominal pain and vaginal bleeding, but syncope can be part of the presentation. Adnexal tenderness or fullness is present in about 50 percent of patients with ectopic pregnancy and also in about 15 percent of patients with threatened abortions. (http://crashingpatient.com/ob-gyn/5358.htm.)
Patients should be screened with a stat pregnancy test, a transvaginal ultrasound, serum beta-hCG, and type and screen. All patients diagnosed with ectopic pregnancy require an OB-Gyn consultation. Some patients only require close follow-up after the OB-Gyn evaluation if they are stable enough to avoid the OR or if ultrasound findings are indeterminate because studies have shown that as many as 15 percent of indeterminate ultrasounds end up being ectopic pregnancies. (Ann Emerg Med 1989;18:48.)
With a beta-hCG of 1200–1500, endovaginal ultrasound should reveal an intrauterine pregnancy; with a beta-hCG over 6500, an intrauterine pregnancy can typically be seen on simple transabdominal pelvic ultrasound. The beta-hCG level should increase by 66 percent every 1.8 to three days for the first six to seven weeks beginning eight to nine days after ovulation in normal intrauterine pregnancy. Symptomatic patients with hCG over 1500 are much more likely to have an ectopic or abnormal pregnancy. (Emergency Medicine Practice 2003;5.) If the beta-hCG is over 1000 and no intrauterine pregnancy is observed on ultrasound, the patient requires a two-day follow-up with OB-Gyn in two days for repeat beta-hCG levels.
Methotrexate is often the treatment of choice by OB-Gyn for patients with a beta-hCG over 3000 who are hemodynamically stable, reliable, and available for follow-up. Patients are advised to avoid folic acid, alcohol, and intercourse until the beta-hCG returns to normal. Ruptured ectopic pregnancies and ectopic pregnancies with beta-hCG over 3000, a mass over 4 cm, or cardiac activity typically require laparoscopy. Be mindful of patients in the first two weeks post-methotrexate treatment with abdominal pain and vaginal bleeding. Obtain an ultrasound and hematocrit to rule out a ruptured ectopic that failed therapy versus methotrexate side effects. If unsure, patients should be admitted and observed using serial examinations and hematocrit. (Tintinalli's Emergency Medicine, 7th edition; New York: McGraw-Hill, 2011 [Ch. 101].)
Pocket Guide for Residents
EMRA'S Basics of Emergency Medicine is a chief complaint-based pocket guide provided to all first-year emergency medicine residents in their welcome packet from the Emergency Medicine Residents' Association. It is also available for $12 ($7 for residents) on www.EMRA.org and www.ACEP.org. It was scheduled to be released as an iPhone app at the ACEP Scientific Assembly in October.