Written by Rebecca Breed
The Canadian Syncope Risk Score (CSRS) can be used to help guide disposition for ED patients with syncope. Admit those in the high and very high-risk categories. Discharge those at very low and low risk. Use shared decision making in those at medium risk. The best part is the online “Team Venk” calculator and patient infographics!
Why does this matter?
Syncope accounts for ~1% of all ED visits; approximately 10% will have a serious underlying condition that caused the syncopal event (arrhythmia, PE, etc). If a cause is not easily identified in the ED, it can be tempting to admit patients for further diagnostic work-up. Using a risk stratification tool such as CSRS can help guide provider disposition decisions and hopefully avoid unnecessary hospital admissions.
“I done fell out…now what?”
This study pooled data from two large cohort studies (CSRS derivation and validation cohorts) which were prospective studies in 11 Canadian EDs from 2010-2018. This included a total of 8,233 patients that were greater than 16 years old presenting to the ED with syncope. Using CSRS scores, they were able to divide patients into differing risk categories to help guide management decisions. In the very-low and low-risk groups, <1% had any serious outcome. In the medium risk group, 7.8% had serious outcomes (<1% death). In the high risk and very high-risk patient groups, serious outcomes were present in >20% (4-6% deaths), though the number of patients in these two groups were a small percentage of the total pooled cohort (6.2%). Based on the above data, authors recommend that very-low and low-risk patients can be discharged, and high-risk patients should be hospitalized for further work-up and monitoring. Medium risk patients can be admitted or discharged depending on ability to obtain close outpatient follow-up and shared decision making with the patient.
While the pooled cohort was large, there are several important limitations including the variability of a clinician’s judgment on type of syncopal episode (vasovagal vs cardiac vs neither) and lack of standardized protocol for obtaining a troponin and EKG.
Personalised risk prediction following emergency department assessment for syncope. Emerg Med J. 2021 Nov 5;emermed-2020-211095. doi: 10.1136/emermed-2020-211095. Online ahead of print.