Syncope is a common presentation to the Emergency Department (ED); however, appropriate management and indications for hospitalization remain an ongoing challenge. The objective of this study was to determine if a predefined decision rule could accurately identify patients with syncope likely to have an adverse outcome or critical intervention. A prospective, observational, cohort study was conducted of consecutive ED patients aged 18 years or older presenting with syncope. A clinical decision rule was developed a priori to identify patients at risk if they met any of the following 8 criteria: 1) Signs and symptoms of acute coronary syndrome; 2) Signs of conduction disease; 3) Worrisome cardiac history; 4) Valvular heart disease by history or physical examination; 5) Family history of sudden death; 6) Persistent abnormal vital signs in the ED; 7) Volume depletion; 8) Primary central nervous system event. The primary outcome was either a critical intervention or an adverse outcome within 30 days. Among 362 patients enrolled with syncope, 293 (81%) patients completed their 30-day follow-up. Of these, 201 (69%) were admitted. There were 68 patients (23%) who had either a critical intervention or adverse outcome. The rule identified 66/68 patients who met the outcome for a sensitivity of 97% (95% confidence interval 93-100%) and specificity of 62% (56-69%). This pathway may be useful in identifying patients with syncope who are likely to have adverse outcome or critical interventions. Implementation and multicenter validation is needed before widespread application.

underwent head CT and comprise the study cohort. Ninety-five patients (84%) were admitted to the hospital. Five patients, 5% (95% CI=0.8%-8%), had an abnormal head CT: 2 subarachnoid haemorrhage, 2 cerebral haemorrhage and 1 stroke. Post hoc examination of patients with an abnormal head CT revealed focal neurologic findings in 2 and a new headache in 1. The remaining 2 patients had no new neurologic findings but physical findings of trauma (head lacerations with periorbital ecchymoses suggestive of orbital fractures). All patients with positive findings on CT were >65 years of age. Of the 108 remaining patients who had head CT, 45 (32%-51%) had signs or symptoms of neurologic disease including headache, trauma above the clavicles or took coumadin. Limiting head CT to this population would potentially reduce scans by 56% (47%-65%). If age >60 were an additional criteria, scans would be reduced by 24% (16%-32%). Of the patients who did not have head CT, none were found to have new neurologic disease during hospitalisation or 30-day follow-up. Conclusions: Our data suggest that the derivation of a prospectively derived decision rule has the potential to decrease the routine use of head CT in patients presenting to the ED with syncope. Keywords CT • Head • Syncope IntroductionSyncope accounts for approximately 1%-3% of all ED visits and up to 6% of all hospital admissions nationwide [1,2]. The cost of care per hospital admission has been estimated at roughly $5300 per stay for a total cost of over $2 billion per year nationally [2]. These costs may correlate with the challenges the emergency physician (EP) faces in evaluating syncope. The EP must identify which patients with lifethreatening causes of syncope require immediate treatment and which patients, despite appropriate workup, still require further evaluation [3]. Up to 60% of patients do not have a readily diagnosed aetiology based on initial history, physiIntern Emerg Med (2007) Abstract Although head CT is often routinely performed in emergency department (ED) patients with syncope, few studies have assessed its value. Objectives: To determine the yield of routine head CT in ED patients with syncope and analyse the factors associated with a positive CT. Methods: Prospective, observational, cohort study of consecutive patients presenting with syncope to an urban tertiary-care ED (48 000 annual visits). Inclusion criteria: age ≥18 and loss of consciousness (LOC). Exclusion criteria included persistent altered mental status, drug-related or post-trauma LOC, seizure or hypoglycaemia. Primary outcome was abnormal head CT including subarachnoid, subdural or parenchymal haemorrhage, infarction, signs of acute stroke and newly diagnosed brain mass. Results: Of 293 eligible patients, 113 (39%)

Levels of haemostatic variables that may be involved in thrombogenesis have been compared in groups of men of similar mean age in communities at very low (Gambia), high (England and Czechoslovakia) or very high (Scotland and Finland) risk of ischaemic heart disease (IHD). There was a consistent gradient of higher factor VII levels with higher IHD risk and also suggestive gradients in the case of two other vitamin K dependent factors, factors II and X. Mean platelet counts were lower and mean fibrinolytic activity was greater in Gambian men than in European men. There was a suggestive though not entirely consistent association between mean fibrinogen levels and IHD risk in the groups from IHD-endemic countries. The results as a whole, and particularly those on factor VII, strengthen the case for the increasingly detailed epidemiological as well as laboratory investigation of the role of the haemostatic system in thrombogenesis and IHD.

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