ABSTRACT
Syncope is a common occurrence in the emergency department, accounting for approximately 1% to 3% of presentations. Syncope is best defined as a brief loss of consciousness and postural tone followed by spontaneous and complete recovery. The spectrum of etiologies ranges from benign to life threatening, and a structured approach to evaluating these patients is key to providing care that is thorough, yet cost-effective. This issue reviews the most relevant evidence for managing and risk stratifying the syncope patient, beginning with a focused history, physical examination, electrocardiogram, and tailored diagnostic testing. Several risk stratification decision rules are compared for performance in various scenarios, including how age and associated comorbidities may predict short-term and long-term adverse events. An algorithm for structured, evidence-based care of the syncope patient is included to ensure that patients requiring hospitalization are managed appropriately and those with benign causes are discharged safely.
Subject(s)
Decision Making , Risk Assessment , Syncope/diagnosis , Syncope/etiology , Automobile Driving , Biomarkers/blood , Brugada Syndrome/diagnosis , Cardiovascular Diseases/diagnosis , Carotid Sinus , Critical Pathways , Diagnosis, Differential , Diagnostic Imaging , Drug-Related Side Effects and Adverse Reactions , Electrocardiography , Emergency Medical Services , Humans , Hyperglycemia/diagnosis , Hypotension, Orthostatic/diagnosis , Ischemic Attack, Transient/diagnosis , Massage , Medical History Taking , Mental Disorders/diagnosis , Physical Examination , Practice Guidelines as Topic , Risk Factors , Seizures/diagnosis , Stroke/diagnosis , Syncope/epidemiologyABSTRACT
BACKGROUND: Point-of-care tests for toxicological screening of patients for drugs of abuse and therapeutic drugs may be helpful in the emergency department (ED) to assist in a rapid diagnosis. OBJECTIVES: In this prospective study, the performance of TesTcard9® (Varian; Middelburg, Netherlands), Syva RapidTest d.a.u. 10® (Dade Behring; Leusden, Netherlands), and Triage TOX Drug Screen® (Biosite; Bunnik, Netherlands), when applied on-site in the ED by physicians and nurses, was evaluated. METHODS: Patients in the ED were included in the study when a physician thought the patient could benefit from a toxicological screen. Urine samples were screened utilizing the three point-of-care tests. All three tests simultaneously determined the presence of amphetamines, methamphetamine, opiates, methadone (except for TesTcard9), cocaine, cannabis, barbiturates, benzodiazepines, tricyclic antidepressants, and phencyclidine. The same urine specimen was analyzed in the pharmacy department using Syva EMIT II immunoassay and chromatographic confirmation. The results were compared for agreement. RESULTS: During the 6-month study period, 80 urine samples were screened. In total, 62 (78%) specimens were found positive for at least one drug. Amphetamines (n = 16), cocaine (n = 27), cannabis (n = 25), benzodiazepines (n = 25), and opiates (n = 8) were the most frequently found. The sensitivity and specificity of all three devices were higher than 93% for these compounds, with the exception of the sensitivity for cannabis with the TesTcard9 (88%) and the sensitivity for benzodiazepines with the Syva RapidTest d.a.u. 10 (88%) and TesTcard9 (80%). CONCLUSION: In the ED setting, the Triage TOX Drug Screen performed better than the other point-of-care tests, probably due to its more objective reading system and its adequate quality controls.
