Syncope and ECG Changes

I was listening to CQI when a case of syncope came up, and the conversation turned to CDU syncope, and it got me thinking about serial ECGs and troponins in ECGs and eventually I started to think about why do we care about ECGs in syncope patients- and then we got to this POTD. So lets get chatting. 

Syncope is defined as a transient loss of consciousness that is self limited and accompanied by transient lose of tone. Approximately 50% of the time when a patient presents to the ED with syncope, there is an etiology determined, 50% of the time it is unclear why a patient syncopizes. Of that 50% of the time the reason is determined it is usually from a detailed history and physical exam, not often found from studies. 

What I wanted to focus on today was the 9.5-18% of the time when syncope is related to a cardiac cause. This is often due to the patient having an underlying cardiac etiology and is associated with a high rate of mortality and an elderly population. 

SO- you are looking at an ECG what should you be looking for in a patient with syncope? I normally am not a mnemonic person but thought this was a helpful one I came across: “ABCDE Left Right” 

A: AV Block: 

• First start by looking at the PR interval: 

• PR >200 ms: First Degree heart block, could be causing dizziness and syncope 

• Notice a pattern between p waves and morphology: 

• Dropped QRS complex with a normal P wave: Second Degree Mobitz type 1: (Wenckebach) 

• Dropped QRS with a fixed PR interval: Mobitz type II 

• Atrial and ventricular dissociation: Third Degree Heart Block

B: Brugada Pattern: 

• Type 1: Coved pattern in leads V1/V2

• Type 2: Saddleback appearance in the ST segment in V1/V2

• Caused by a genetic mutation in the sodium channel of cardiac myocytes

• Patient will have a family hx of sudden cardiac death

C: QTc Prolongation 

• QTc is considered prolonged if it measures more than 440 ms in males/460 ms in females 

• Should be measured from the end of the beginning of the QRS complex to the end of the T wave 

• Typically measured in lead II or V5/V6 

• Etiology to include a variety of electrolyte abnormalities: hypoK, hypoMg, hypCa, increased ICP, or medication induced, or genetic (Long QT Syndrome) 

• In the case of genetic conditions, also consider if the patient has a family hx of sudden cardiac death

D: Delta Waves

• A classic delta wave: shortened PR interval with slurred QRS upstroke is pathognomonic for Wolff Parkinson White Syndrome (WPW)

• Caused by an electric conduction along an accessory pathway 

• Look for these in limb leads and/or precordial leads 

E: Epsilon Waves 

• Epsilon wave: inflection point between the QRS and the ST segment pathognomonic for arrhythmogenic right ventricular cardiomyopathy (ARVD)

• Typically seen in leads V1 and/or V2

• ARVD: is a genetic condition that presents with conduction impairment due to fatty fibrous deposits in the cardiac myocytes 

Left: 

• Evidence of Left ventricular hypertrophy

• Could represent any signs for left heart strain including HCOM, aortic stenosis, coarctation, aortic regur, mitral regurg 

• Huge precordial R and S waves that overlap with adjacent leads 

• LV strain pattern with ST depression and T wave inversions in I, aVL, and V5-6

Right: 

• Evidence of right ventricular strain: ST segment depressions and T wave inversions in the right sided leads (V1-V4) and/or inferior limb leads II, III, AVF usually with right axis deviation 

• Concern for right ventricular strain would be concerning for pulmonary embolism 

• Must look for SIQ3T3 

TLDR: 

• Syncope and ECGs, take a look at ABCDE Left Right:

• AV Block: look at your PR interval and P and QRS morphology

• Brugada: look at V1/V2 for saddleback deformities

• QTc Prolongation: more than double the R-R is long! 

• Delta wave: upswinging QRS in the precordial/limb leads

• Epsilon wave: inflection at the QRS between ST segment at V1/V2 concerning for ARVD

• Left heart strain: huge R and S waves

• R heart strain: signs of strain in the right sided/inferior leads 

https://www.emdocs.net/ecg-pointers-7-cant-miss-ecg-patterns-of-high-risk-syncope-the-abcde-left-right-mnemonic/

https://litfl.com/left-ventricular-hypertrophy-lvh-ecg-library/

https://litfl.com/syncope/

Match Day- A History

Happy Match Day to those who celebrate! For a Wellness/Feel Good Friday- I thought it would be fun to take a look at the history of Match Day and explain for our colleagues who did not fortunately experience the chaos of the match!

Match day started in the 1950s as a way to try to control the chaos of hospitals hiring medical students during the end of their medical school training. The offering of jobs started to become more and more ridiculous with students being offered halfway through medical school and given 12 hours to respond to offers. In 1952, a centralized matching process and the organization known as National Resident Matching Program (NRMP) was formed. 

This process has evolved over the years and has become a computerized algorithm. Today, the match process started in September of a student's fourth year of medical school. At that time, an extensive application is pieced together including undergraduate/medical transcripts, national board exam scores, letter of recommendations, evaluations from all rotations, a personal statement, a list of extracurricular activities, and essentially anything that you have done leading up to that point in your life. This application is sent out to residency programs. 

When applying for residency programs you apply specifically to a hospital and speciality. This means that most candidates are picking a speciality prior to applications, though it is often for people to dual apply, meaning they apply for two different specialities. Usually when this happens, there is a more competitive speciality that they are anticipating needing a back up plan. Or they truly cannot decide what they want to do yet. 

This year, approximately 50,000 medical students (a combination of MDs, DOs, and IMGs (international medical graduates) applied this cycle, which is fairly similar to the more recent years. Applicants will apply to programs and pay a fee. On average, the US MD applicant applied to 71 programs and US DO applicants on average apply to 93 programs. Applicants spend the next few months interviewing. Prior to covid, applicants flew over the country and interviewed in person, now these interviews are mostly virtual. Applicants are offered interviews usually to a fraction of programs, and depending on the competitiveness of the speciality and the candidate, a person is not guaranteed any interviews. 

After interviewing, applicants can put programs on a rank list. Each person ranks their programs and enters a formal rank list in the beginning of February. At the same time, each program ranks all of the applicants who were interviewed. This enters a computer algorithm which favors the applicants. The NMRP describes this preference as, “The matching algorithm is “applicant-proposing “meaning it attempts to place an applicant (Applicant A) into the program indicated as most preferred on Applicant A’s rank order list. If Applicant A cannot be matched to this first choice program (because the program doesn’t also prefer Applicant A), an attempt is then made to place Applicant A into the second choice program, and so on, until Applicant A obtains a tentative match, or all of Applicant A’s choices have been exhausted (meaning Applicant A cannot be tentatively matched to any program on the rank list).” 

This process ends when all applicants are considered and ranked to their highest ranking program. For some context, Maimonides received approximately 1000 applications, interviewed 250 applicants, and matched a class of 18 incoming residents. 

This process does not always have a happy ending. During Match Week, which occurs the third week of March- the first significant day is Monday. On Monday, all applicants receive an email notification signaling if they matched into a program or not. This year, Emergency Medicine residency programs filled 97.9% of their spots, which was an increase after there was a decline at 81% in 2023. For some context, other specialities such as OBGYN had 10 national spots open in the entire country out of approximately 1100 spots. 

Nationally, for US MD/DO students the rate of matching is ~93%, compared to 67.8% of US citizens with international medical graduates, and 58% of non US citizen IMGs who matched. 

For those who unfortunately do not match, they enter a process called the SOAP (Supplemental Offer and Acceptance Program) which attempts to find unmatched applicants with unfilled positions. This becomes a whirlwind race to virtually interview, receive offers, and accept positions over a 3 day period. 

The Friday of Match Week is the infamous Match. Applicants either return to their school and receive a printed letter which they open in front of colleagues, peers, family, and faculty or they opt to open their email at home all of which lists which program you are slotted to start on July 1st. Once you are placed in this spot, that is it. You cannot change your mind on locations, specialities, or timing without restarting the process and entering the match next year. 

Fortunately for us, Maimonides welcomed 18 brand new interns who hopefully opened their letters and emails today with joy and a sense of accomplishment. Every doctor can tell you about their match day, the anxieties leading up to it, the relief, the joy, the tears. It’s one of the most insane experiences I have ever lived through. 

So with that- Happy Match Day to those who celebrate, a huge shoutout to our recruitment team who works tirelessly combing through applications to find our special group of 18 who will come home to Maimo and learn the wonders of Southside later this year.

https://www.nrmp.org/intro-to-the-match/match-fees/

https://www.nrmp.org/intro-to-the-match/roles-responsibilities/

https://www.ama-assn.org/medical-students/preparing-residency/biggest-match-day-ever-here-s-what-2025-numbers-reveal#:~:text=Emergency%20medicine's%20rebound,were%2098%25%20to%2099%25.

https://www.ama-assn.org/medical-students/preparing-residency/heres-how-many-residency-programs-med-students-really-apply

https://students-residents.aamc.org/applying-residencies-eras/applying-residencies-eras-system

Itching in the ED

I think one of the most uncomfortable things in the world is being itchy. As a girl who has been taking an Allegra every single day since I was 8 years old, I thought we could do a bit of a deep dive into being itchy. 

The medical term for itch is defined as pruritus. Itches can be categorized into four big groups: Neurogenic, psychogenic, neuropathic, and pruitrioceptive causes. 

1. Neurogenic itching: thought of as more of a systemic itch, the itch starts from the central nervous system as a result of other disorders of organ systems besides the skin. 

1. This can be seen in patients with chronic renal failure, liver disease, hematologic and lymphoproliferative diseases and malignancies

2. The pathophysiology behind this is not completely understood but it is not through a direct neuronal pathway and often improves with opioids 

3. The thought behind this is that these pathologies cause increase secretion of intraspinal endogenous opioids which is why it is partially responsive to opioid antagonists 

2. Psychogenic itching: usually a diagnosis of exclusion as the pathophysiology is not fully understood

1. Usually presents with impulses to scratch or pick 

2. Often associated with depression, OCD, anxiety, mania, substance induced psychosis, or somatoform disorders 

3. Most well known is parasitosis: a specific delusion where patients believe there is some sort of insect or parasite living under their skin that they must scratch away 

3. Neuropathic itch: caused by central or peripheral neurons that are damaged that inappropriately fires pruritic neurons causing the sensation of itching without any cutaneous etiology. 

1. Often accompanied by paresthesia, hyperesthesia, hypoesthesia  

2. The exact mechanism is unknown though thought to be due to specific damage due to the C fibers

4. Pruritoceptive Itch: most common encountered. Usually generated by through inflammation thorough skin damage 

1. This is a plug to TRULY look at a patient’s skin. If there is a rash besides urticaria or wheals, that sets you down an entirely different pathway, which is not the purpose of this discussion. This discussion is for good old, generalized, full body itching. 

2. To avoid a true histologic lecture, the short of it is that itching is perceived through C fibers that are unmyelinated that are able to interact with keratinocytes in skin that react directly to pruritogens. 

3. There is a theory that the nerves that perceive pain (nocireceptors) are able to block the sensation of itching therefore scratching does not relieve itching but rather it just blocks the sensation of itching providing temporary relief 

4. Certain mediators are able to trigger the response of itching: 

1. Histamine

2. Triptase

3. Interleukin 34

4. Leukotrine B4

5. Substance P

Okay- so now that we understand at a cellular level what is causing a patient to itch- now what? 

1. As always the first step is determining if this is a systemic or local process: 

1. Is this coming from a neurogenic perspective for example does this patient have renal failure or CKD and maybe this pruitius is a symptom of their worsening uremia? 

2. Does this patient have a systemic rash, swelling of the oropharynx and recently ate a dish with peanuts that they have a known allergy to? Consider anaphylaxis and a hypersensitivity reaction and treat appropriately 

3. Does the patient have an infectious reason for their itching? Are they covered in little insect bites? Do they have lice in their hair? Consider there are many little critters that will cause generalized itching 

2. Stabilize the patient 

1. Go back to your ABCs 

3. Determine if there is a need for additional work up?

1. Does this patient need labs to see if there is an infectious etiology or end organ damage? Consider a CBC, BMP, LFTs, lipase 

4.  If truly just urticaria: treat!

1. Non-pharmacological interventions:

1. Moisturizer: avoid fragrances 

2. Cool environments: cold packs, ice, cool shower

3. Avoid irritants 

2. Topical therapies: 

1. Corticosteroids 

1. Avoid the face and long term use 

2. Capsicin

3. Systemic therapies:

1. Antihistamines: Benadryl (sedating) vs cetirizine/loratadine (nonsedating)

2. Other more extreme causes with other systemic, noncutaneous causes can consider opioids, SSRIs, or immunosuppressants

3. Corticosteroids
   I would be wary about starting any of these in patients outpatient or long term and encourage these patients to follow up outpatient

Well, now that we are all sufficiently scratching, heres at least a start to approaching that itchy patient in 22 hallway!

Garibyan L, Rheingold CG, Lerner EA. Understanding the pathophysiology of itch. Dermatol Ther. 2013 Mar-Apr;26(2):84-91. doi: 10.1111/dth.12025. PMID: 23551365; PMCID: PMC3696473.

Lerner EA. Pathophysiology of Itch. Dermatol Clin. 2018 Jul;36(3):175-177. doi: 10.1016/j.det.2018.02.001. Epub 2018 Mar 20. PMID: 29929590; PMCID: PMC6022764.

Macy E. Practical Management of New-Onset Urticaria and Angioedema Presenting in Primary Care, Urgent Care, and the Emergency Department. Perm J. 2021 Nov 22;25:21.058. doi: 10.7812/TPP/21.058. PMID: 35348101; PMCID: PMC8784078.

Nowak DA, Yeung J. Diagnosis and treatment of pruritus. Can Fam Physician. 2017 Dec;63(12):918-924. Erratum in: Can Fam Physician. 2018 Feb;64(2):92. PMID: 29237630; PMCID: PMC5729138.