The diagnostic efficiency of whole body approach targeted bedside ultrasonography in patients presenting to the emergency department with syncope

Ultrasonography in Patients Presenting to the Emergency Department with Syncope Introduction Syncope is a rapid-onset, short-term, temporary loss of consciousness and posture due to cerebral hypoperfusion that progresses with complete cognitive recovery. Risk stratification, etiology investigation and discharge decision for syncope are challenging for emergency physicians. In current medical practice, many clinical decision rules have been developed to evaluate syncope and presyncope patients with a standardized approach and to identify patients with high risk factors. However, imaging methods are not yet used in these risk scorings. Today, the use of ultrasonography in high-risk emergency department admissions has become a standard in emergency medicine practice. While USG is widely used on many patient groups in the emergency department, an ultrasonography protocol has not yet been developed for patients with syncope or presyncope that may develop due to a life-threatening disease. The aim of our study is to reveal whether the whole body ultrasonography (WHOBUS) technique recognizes highrisk syncope patients in patients who apply to the emergency department with syncope or presyncope, and to reveal the effectiveness of the patient in the diagnosis and treatment processes. Material and Method In our prospective cross-sectional study, syncope/presyncope patients over the age of 18 who applied to the emergency department were included. The ultrasonography protocol was performed by 4 practitioners who were unaware of the patient's clinical findings. For the WHOBUS technique, carotid, lung, cardiac, abdominal ultrasonography and compression ultrasonography of the lower extremities were used to examine deep vein thrombosis and abnormal findings were recorded. Changes in physician decisions regarding the etiology of syncope after and before WHOBUS were evaluated. Treatment interventions applied to patients due to abnormal findings found during USG evaluation were evaluated separately as major and minor interventions. Independent risk factors were determined by logistic regression model for the detection of abnormal WHOBUS findings and USG findings requiring major intervention. x Results 152 patients were included in the study. The median age of the patients was 61.5 years (IQR: 41-71.8) and 52.6% (n=80) were female. The median value of the TVYUS evaluation time of the physicians was determined as 14 minutes (12-16 minutes). As a result of WHOBUS evaluation, ultrasonographic findings or findings associated with syncope / presyncope or thought to cause syncope were detected in 54 (35.5%) of the patients. Major intervention was performed in 29 (19%) of the patients, and minor intervention was performed in 68 (44.7%) of the patients for abnormal findings detected by WHOBUS. In 42 of the cases (27.6%), the physician's pre-diagnosis of the etiology of syncope changed after WHOBUS. There was a high level of agreement between the prediagnoses and final diagnoses detected after USG (Kappa: 0.931, p<0.001). At the time of admission, after the anamnesis and physical examination, the physicians in charge of the patients did not require hospitalization in 121 patients, while hospitalization was required in 31 patients. After the TVYUS result was learned, in 12 (9.9%) of 121 patients, the responsible physician changed his decision that the patient should not be hospitalized. In 9 (29%) of the 31 patients who were thought to need hospitalization, the decision was changed that they did not need hospitalization after the WHOBUS result was learned. Conclusion Ultrasonographic findings associated with syncope/presyncope were detected in approximately 1/3 of the patients with TVYUS evaluation. The majority of abnormal findings were seen in patients over 60 years of age. Advanced age, increased heart rate, and presence of ESC high-risk criteria were determined as independent risk factors for abnormal findings. Major intervention was performed in 1/5 of the patients for abnormal findings detected by TVYUS evaluation. Presence of ESC high-risk criteria was determined as an independent risk factor for major intervention for abnormal findings. In patients with syncope or presyncope presenting to the emergency department, WHOBUS can be included in emergency practice as part of the standard evaluation. Key words: Emergency department, syncope, ultrasonography