(P98) A Case for ED POCUS for the Evaluation of Syncope

Chief Complaint : Hyperglycemia, Loss of consciousness

History of Present Illness : 59-year-old female with a past medical history of diabetes mellitus and breast cancer s/p mastectomy presenting for epigastric pain and dizziness for 2 days. Patient was in her otherwise usual state of health until 2 days ago when she began to have epigastric pain. Pain is described as bloating pain in the epigastric region, nonradiating. Pain was not associated with food or with exertion. She presented to the emergency department because she had two episodes of syncope at home. Patient has no history of DKA in the past. Denies fever/chills, cough, GU symptoms, GI symptoms, GYN symptoms. Of note, she was diagnosed with breast cancer in her home country in 2021. At that time, she underwent mastectomy of the left breast as well as chemotherapy and radiation. Testing with her home doctor confirmed she was in remission 5 months prior to this ER presentation.

Pertinent Physical Exam: Vital signs were notable for tachycardia to 119 and BP 105/81. Patient was otherwise afebrile with normal respiratory rate and oxygen saturation. Her FSG read as “HI” on initial triage. General exam was notable for our patient lying on the stretcher not in acute distress, appearing fatigued on exam, with dry mucous membranes. Abdominal exam with mild tenderness to palpate in the epigastric region.

Pertinent Laboratory Data: Patient was initiated on IV fluids for treatment of suspected hyperglycemia resulting from infectious source from triage. Initial blood work was notable for ALT 249, AST 150, and Alk Phos 131. POCUS Transabdominal study was performed to determine biliary pathology resulting in the patient's shock state. Exam of the epigastric region quickly revealed pathology outside of the biliary tract.

Case Discussion: Syncope is a common emergency department chief complaint. The initial work-up for syncope is relatively basic: H&P and an EKG (1). Ultrasound is not part of the typical syncope evaluation. In this patient, the working diagnosis in the patient was DKA or HHS in the setting of an underlying infection. Our finding of cardiac tamponade in a well-appearing patient was unexpected.
ED ultrasound is commonly performed in patients with blunt trauma, shock, abdominal pain, and gynecologic emergencies; however, there are very few reports in the literature of critical findings on bedside ultrasound in ED patients with syncope (2,3). Unexpected diagnoses for syncope that can be identified via ultrasound include pulmonary embolism and aortic emergencies. In our literature search of bedside POCUS for syncope, we only found a single case report of cardiac tamponade diagnosed on bedside ultrasound (4). As the technology for bedside ultrasound becomes more widely available and providers incorporate POCUS into their everyday practice, there may be immense value in incorporating bedside ultrasound for the evaluation of syncope. In one prospective study, bedside ultrasound changed the patient disposition in 14% of patients (3).
Cardiac tamponade itself can be a challenging diagnosis, especially those who develop pericardial effusion gradually. The sensitivity of clinical signs of muffled heart sounds, hypotension, and distended neck veins (Beck’s Triad) can be as low as 20% (5). Therefore, since syncope is often related to hypotension, a bedside ultrasound may have diagnostic value in syncope, particularly in patients who initially present without an obvious diagnosis.

References and Acknowledgements (Optional): 1. Shen WK, Sheldon RS, Benditt DG. 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope: A report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines and the Heart Rhythm Society. Circulation 2017; 136:e60-e122.
2. Tung-Chen Y, Halperin M, Short-Apellaniz J. Orthostatic syncope as a presentation of pulmonary embolism, a not to be missed diagnosis. Visual J Emergency Medicine 2019 5-6.e1.
3. Ucar G, Aksay E, Bayram B. The diagnostic efficiency of whole-body bedside ultrasonography protocol for syncope patients in the emergency department. Am J Emerg Med 2023, 67:17-23.
4. Conti RA, Oppenheim IM. Low-pressure cardiac tamponade masquerading as severe sepsis diagnosed with a bedside ultrasound and as the initial presentation of malignancy. J Community Hosp Intern Med Perspect 2014; 4(3) eCollection 2014.
5.Stolz L, Valenzuela J, Situ-LaCasse E, Stolz U, Hawbaker N, Thompson M, Adhikari S. Clinical and historical features of emergency department patients with pericardial effusions. World J Emerg Med. 2017;8(1):29-33. doi: 10.5847/wjem.j.1920-8642.2017.01.005. PMID: 28123617; PMCID: PMC5263032.