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European Heart Journal Advance Access originally published online on December 16, 2007
European Heart Journal 2008 29(5):618-624; doi:10.1093/eurheartj/ehm563
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Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2007. For permissions please email: journals.permissions@oxfordjournals.org

Physical injuries caused by a transient loss of consciousness: main clinical characteristics of patients and diagnostic contribution of carotid sinus massage

Angelo Bartoletti1,*, Plinio Fabiani2, Luciano Bagnoli3, Carlo Cappelletti2, Marco Cappellini3, Gino Nappini3, Roberto Gianni3, Alessandro Lavacchi3 and Giovanni Maria Santoro1

1 Cardiology Division, Nuovo San Giovanni di Dio Hospital, Florence, Italy
2 Internal Medicine Department, Nuovo San Giovanni di Dio Hospital, Florence, Italy
3 Emergency Department, Nuovo San Giovanni di Dio Hospital, Florence, Italy

Received 24 February 2007; revised 24 October 2007; accepted 12 November 2007; online publish-ahead-of-print 16 December 2007.

* Corresponding author: Costa dei Magnoli 28, 50125 Florence, Italy. Tel: +39 055 2346149, Fax: +39 055 7192399, Email: angelobartoletti{at}alice.it

See page 576 for the editorial comment on this article (doi:10.1093/eurheartj/ehm637)


   Abstract
Top
 Abstract
Introduction
 Patients and methods
 Results
 Discussion
 Practical implications
 References
 
Aims: To evaluate the prevalence and the characteristics of secondary trauma among patients referred to the emergency department (ED) for a transient loss of consciousness (TLOC).

Methods and results: Over a 24 months period, all the patients referred to our ED for a TLOC were evaluated according to the ESC Guidelines on Syncope and enrolled in the study. Among 1253 consecutive patients with TLOC (1114 with a true syncope and 139 with a non-syncopal condition) 365 (29.1%) reported a trauma, in 59 cases (4.7%) severe. The frequency and the characteristics of trauma did not differ among the two main categories of TLOC. Out of 54 patients with syncope and a severe trauma, 20 (37%) had a definite diagnosis after a guidelines-based initial evaluation, and further 17 (31.5%) during the hospital course. Among these latter, carotid sinus syndrome was by far the most common diagnosis.

Conclusion: Among patients referred to the ED for a TLOC secondary trauma is a common complication, whose characteristics are of little utility to discover the specific cause of the symptom. For older patients with syncope complicated by a severe trauma carotid sinus massage should be the first diagnostic manoeuvre to be undertaken after a non-diagnostic initial evaluation.

Key Words: Transient loss of consciousness • Syncope • Physical injury • Carotid sinus massage


   Introduction
Top
 Abstract
 Introduction
Patients and methods
 Results
 Discussion
 Practical implications
 References
 
Secondary trauma is recognized as one of the most harmful complications of transient loss of consciousness (TLOC),1–5 and severe trauma is included among the indications for hospital admission of patients referred for such clinical symptom.6,7 The rationale of the indication is to define the exact mechanism of TLOC in order to apply a specific treatment and to prevent both the recurrences and the associated physical injuries. Despite the practical importance of this issue, the only data available focus on elective patients with documented8 or suspected9 vasovagal syncope, while the main clinical characteristics of secondary trauma have not been systematically evaluated until now among unselected patients with TLOC.

Furthermore, the recent European Society of Cardiology (ESC) Guidelines on Syncope6 listed a definite group of non-syncopal conditions and suggested the differential diagnosis between these latter and the true syncope as the basic diagnostic step for patients referred for a TLOC. At present, data on secondary trauma among patients with non-syncopal TLOC are totally lacking.

Aims of the present study were to evaluate the prevalence of trauma in a population of consecutive patients referred to the emergency department (ED) for a TLOC; to detect (if any) the different clinical characteristics of trauma among patients with syncope or with a non-syncopal condition; to assess whether differences exist in the clinical characteristics of patients and in the circumstances of the index episode between syncopes with and without secondary trauma; to evaluate the prevalence of trauma in relation to the specific causes of syncope; and to evaluate the diagnostic and prognostic implications of severe trauma in patients with syncope.


   Patients and methods
Top
 Abstract
 Introduction
 Patients and methods
Results
 Discussion
 Practical implications
 References
 
Setting
The Nuovo San Giovanni di Dio (NSGD) is a public General Hospital provided with an ED working 24 h a day and all the diagnostic tools with potential indication in patients with TLOC.7 From August 2002, at the NSGD, a multidisciplinary Syncope Unit (SU) including the ED was in operation. One of the main targets of the SU was the monitoring of all the TLOC presentations and the related admissions. Therefore, the clinical data concerning such patients were prospectively collected and stored in a dedicated database. A specific target of the above activity was the secondary trauma owing its importance for both the decision to admit and the following diagnostic implications.6–7

Patients' clinical assessment
All the patients referred for a TLOC underwent an initial evaluation during the ED stay comprehensive of history, physical examination, blood pressure assessment in both clino- and orthostatic position, 12-lead ECG, and routine blood examinations. Further diagnostic investigations, as well as hospital admission and specialist consultations, were performed only when clinically indicated.6

Definitions
According to the specific ESC Guidelines, syncope was defined as a spontaneous and transient TLOC, usually associated with fall, and with spontaneous, quick, and complete recovery as well.6 All the conditions listed by the ESC Guidelines as non-syncopal conditions6,10,11 were considered as a separate setting. According to the local previous clinical practice, very restrictive definitions of non-syncopal attack were applied in our hospital (Table 1). The term of TLOC was used to indicate together the cases of true syncope and the non-syncopal conditions. Based on the previous definitions those patients with TLOC caused by trauma (concussion), as well as those with only minor disorders of consciousness, such as pre-syncope or near-syncope6,10,11 were excluded.


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  		Table 1 Criteria for the diagnosis of the non-syncopal causes of transient loss of consciousness

 
The definitions of cardiac syncope (including both syncope related to primary arrhythmia and to structural cardiopulmonary disease), vasovagal syncope, situational syncope, and carotid sinus syndrome (CSS) were those reported in the ESC Guidelines.6 Orthostatic syncope was diagnosed in case of documented orthostatic hypotension12 associated to syncope or near-syncope. Syncope associated to haemorrhage or anaemia was diagnosed when a major bleeding requiring haemotransfusion was documented. In all the other cases the syncope was defined of unknown origin.

Trauma was defined any physical injury secondary to TLOC clinically relevant enough to be mentioned in the patients' clinical records. Trauma was defined as severe when caused: skull or other major bone segments fracture; intracranial haemorrhage; internal organ lesions requiring urgent, specific treatment; retrograde amnesia or focal neurologic defect.

Structural heart disease indicated: chronic coronary heart disease; cardiomyopathy (dilated or hypertrophic) or valvular disease with documented left ventricular dysfunction and/or obstacled ventricular afflux and/or efflux; and hypertensive heart disease (high blood pressure with left ventricular hypertrophy and/or dysfunction).

Electrocardiographic (ECG) abnormalities indicated only those abnormalities of the basal ECG listed by the specific ESC Guidelines as suspected for a cardiac arrhythmia, with the need to be confirmed by directed testing.6

Data evaluation
The total number of the ED presentations during the monitoring period, as well that of patients observed for a TLOC was acquired. Among these latter, the patients diagnosed as having a true syncope or a non-syncopal condition were separated. Subsequently, the number of TLOC with a secondary trauma and the related clinical characteristics were acquired by the patients' records. In a first phase, the characteristics of trauma were compared between patients with a true syncope and those with a non-syncopal condition. In a second phase, the characteristics of trauma were compared among the different subgroups of patients with syncope. Finally, the diagnostic pathway was assessed for those patients with a true syncope and a secondary, severe trauma. For these latter patients, 12 months after discharge, informations were collected by a phone call regarding survival and syncope recurrences.

Statistical analysis
Absolute numbers and percentages were reported to describe the patient population. Comparisons between groups were performed with Student's t-test for continuous variables and with a continuity-corrected {chi}2 test (or, when indicated, with Fisher's exact test) for proportions. All tests were two-sided and a P-value <0.05 was considered to be statistically significant. All statistical analyses were performed using SPSS software (version 11.5, SPSS Inc., Chicago, IL, USA).


   Results
Top
 Abstract
 Introduction
 Patients and methods
 Results
Discussion
 Practical implications
 References
 
Between 1 September 2002 and 31 August 2004, 1308 patients entered our ED for a TLOC. Out of these, 1114 (85.2%) were finally diagnosed as having a true syncope and 139 (10.6%) a non-syncopal condition, while 55 (4.2%) were excluded because it was not possible to ascertain if a TLOC had really happened. Therefore the study population consisted of 1253 patients (Table 2).


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  		Table 2 Characteristics of the 1253 patients with transient loss of consciousness

 
Trauma occurred in 365 patients (29.1%) and in 59 (4.7%) was severe. The prevalence of trauma and the region of the body involved in patients with a true syncope and with a non-syncopal condition are reported in Table 3. No significant differences were observed between patients with syncope and non-syncopal conditions regarding the prevalence and the location of trauma.


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  		Table 3 Characteristics of trauma among patients with transient loss of consciousness caused by syncope and non-syncopal conditions

 
The clinical characteristics of the 1114 patients with a true syncope and the circumstances of the index episode according to the occurrence or not of secondary trauma are reported in Table 4. Severe trauma occurred more frequently in patients aged >65. Trauma was more frequent when syncope occurred at home, in orthostatic position and without prodromal symptoms. In those two latter situations, the syncope was more frequently complicated by a severe trauma.


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  		Table 4 Prevalence of trauma among the 1114 patients with syncope, based on the clinical characteristics of patients and the circumstances of the syncopal episode

 
The prevalence of trauma in relation to the specific cause of syncope is reported in Table 5. The prevalence of trauma did not differ among the main categories.6 In the group of patients with neurally mediated syncope, those with situational syncope or CSS showed a higher probability of trauma in comparison with patients with the vasovagal form.


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  		Table 5 Prevalence of trauma among patients with syncope, based on the specific cause of syncope

 
The diagnostic pathway for syncope complicated by a severe trauma is reported in Figure 1. The definite mechanism of syncope was diagnosed in 20 out of 54 patients (37%) during the initial evaluation in the ED. Three patients (two with multiple rib fractures, and one with arm fracture) refused the diagnostic hospitalization6 after the ‘urgent’ treatment in the ED. Further two patients with a commotive cranial trauma were discharged after a prolonged observation in the ED according to a pre-existing protocol for cranial trauma but without undergoing any specific test for syncope, and were classified as ‘inappropriately discharged’.7 Among the remaining 29 patients, 17 (31.5% out of the 54) received a definite diagnosis during the hospital phase (diagnostic tests: orthostatic pressure assessment, not performed at the ED: one case; tilt testing: one; carotid sinus massage (CSM): nine; ECG monitoring: two; chest TC scan: two; clinical history reappraisal: two). In summary, a definite mechanism of syncope was found in 37 out of 49 (75.5%) patients who underwent a complete clinical evaluation.


Figure 1
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  		Figure 1 Diagnostic pathway for patients with syncope and severe trauma

 
No deaths occurred as a direct consequence of trauma among the whole population of patients with TLOC neither at the ED nor during the subsequent in-hospital phase. Three patients (two with cardiac syncope and one with syncope of unknown origin) died within 12 months after discharge. The causes of death were, respectively, chronic heart failure, stroke, and pneumonia. Further two patients (one with situational syncope and one with syncope of unknown origin) had a recurrence within 12 months.


   Discussion
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
Practical implications
 References
 
In our series, the incidence of trauma did not differ among patients with a true syncope or a non-syncopal condition. Our data suggest that—at least among those patients referred to the ED for medical evaluation—physical injuries are a common and sometimes severe complication not only of syncope but more in general of TLOC. As a consequence, the simple presence/absence of trauma cannot be assumed as a clinical criterion for distinguishing between the two main categories of TLOC in this specific setting.

Furthermore, no difference was found regarding the location of secondary trauma in patients with TLOC caused by a true syncope or a non-syncopal condition. Nevertheless, the analysis of the site of the body involved by trauma showed that, while head was affected in the majority of the cases, limb fractures (both as isolated injury or in the setting of a multiple trauma) were an exclusive finding of patients with a true syncope. A low incidence of limbs fracture has been reported for patients with epilepsy both as absolute risk13,14 and in comparison to control subjects.15 Overall, these observations suggest a different dynamic of falling for patients with syncope and non-syncopal TLOC.16,17 Provided that the early diagnostic appraisal between the above categories represents a cornerstone in the assessment of TLOC,6 further observations on wider patients' samples should better clarify this specific issue.

As expected, the risk of trauma was greater for syncopes occurring in orthostatic position compared with those occurring while sitting or recumbing. Similarly, trauma was more frequent among patients with syncope not preceded by definite prodroms. Furthermore, the general risk of trauma was greater for patients with syncope occurring at home, indicating home as the most dangerous setting for these falling subjects. This latter observation suggests that patients with syncope at home are less mobile and/or more fragile,4,18,19 and could benefit from a multifactorial risk assessment including architectural or other environment barriers.20,21

As regards the clinical characteristics of patients, no difference was found relative to the risk of trauma depending on sex and, interestingly, on age, history of heart disease, or presence of the abnormalities in the basal ECG listed by the specific ESC Guidelines as suspected for a cardiogenic syncope.6 However, severe trauma was more frequent among older subjects, again suggesting a less rapid reaction to the TLOC and/or a more fragile body structure in this population.4,18

Finally, no difference was found between patients with the index episode representing the first syncope in the lifespan and those with previous syncopal episodes. This finding outlines the need to define for these patients the precise cause of syncope in order to apply a specific treatment (whenever available) or, particularly for those with a neurally mediated syncope, to plan more aggressive educational programs since the in-hospital phase.8

As regards the different specific causes of syncope, an unexpected finding was that cardiac syncope did not imply a higher risk of trauma in comparison with the other main categories. Therefore, the occurrence of trauma does not help in identifying the specific cause of syncope. Since neurally mediated syncope was by far the most frequent form of syncope in our series, a further analysis was performed distinguishing the different causes of syncope in this specific setting.6 Patients with situational syncope and with CSS were more likely to have severe trauma as a consequence of syncope in comparison to patients with the vasovagal form. This finding has practical implications: the severe trauma has been recently advocated as a diagnostic indication for hospitalization for patients with syncope,6 in order to discover the precise mechanism of the symptom and, by the application of a specific treatment, to prevent both the recurrences and the associated, further physical injuries. First of all it should be noted that, as reported for the guidelines-based initial evaluation among the general population of patients with syncope,6,22–24 about 40% of our patients with severe trauma received a definite diagnosis since the ED phase. Such a result is worthwhile in consideration of the clinical characteristics of patients in whom the presence of a complicated cranial trauma or limb fractures often had prevented to obtain a detailed clinical history or to perform even simple diagnostic manoeuvres such as the orthostatic pressure assessment. These data confirm the good applicability of the ESC Guidelines on Syncope since the early hospital phase.7,24

Including the in-hospital phase, 75% of our patients with syncope and a severe trauma finally had a definite diagnosis. Such a value did not differ from that reported by recent papers in the whole population of patients referred to the ED for syncope.7,22–26 Notably, among our patients with syncope complicated by severe trauma and of unknown origin after the initial evaluation, the highest number of diagnoses was obtained by means of CSM. Such a finding may admit several explanations. First of all, CSM is feasible in all the patients as those considered in the present study, often poorly collaborative or affected by physical injuries totally preventing other provocative tests. Furthermore, in our hospital a specific diagnostic protocol is in operation27 which plans CSM as the first diagnostic step after the initial evaluation not only for those patients with syncope aged >40 and without heart disease,6 but also for those with a bundle branch block, provided that a concomitant left ventricular dysfunction has been previously excluded. Since for these patients bradycardia is expected as the most likely mechanism of syncope,28,29 the finding of a CSS allows the most appropriate treatment (a permanent cardiac pacemaker) without the need of further invasive tests.30 Notably, amnesia for TLOC is a common finding among patients with CSS,31 and a high prevalence of carotid sinus hypersensitivity has been reported among older patients with physical injuries caused by unexplained ‘falls’.32 Furthermore, CSM had yet been suggested as a routine manouvre in all the older patients with unexplained symptoms possibly related to bradycardia or hypotension.33 Our data are consistent with the above observations and bring further support to the diagnostic role of CSM, suggesting CSM as the first manouvre to be performed after the initial evaluation at least in the specific subset of older patients with a syncope complicated by severe trauma.

Interestingly, no cases of death were observed as a direct consequence of trauma among our population of patients with TLOC. This finding must be considered cautiously: death as a consequence of trauma may be instantaneous or occur within few minutes, before any medical contact or anyway before hospital admission. Furthermore, in the specific context of Florence where a Trauma Centre is in operation in a tertiary hospital facility, patients with more severe trauma may be directly addressed to such structure without reaching a first level hospital like ours. As a consequence, our data regarding a possible low mortality directly related to secondary trauma among patients with TLOC cannot be generalized.


   Practical implications
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 Practical implications
References
 
The occurrence of trauma, although common, does not help in recognizing the specific cause of the symptom in patients referred to the ED for TLOC. Nevertheless our data suggest that for those patients with syncope complicated by a severe trauma and without a precise diagnosis after the initial evaluation, CSM should be the first diagnostic investigation. Provided that CSM is a simple diagnostic manoeuvre which can be performed in the majority of the clinical settings without the need of specialized facilities, our study suggests that a greater application of this specific test in patients with syncope complicated by severe trauma could improve the diagnostic assessment of these critically ill patients.

Conflict of interest: none declared.


   References
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 Practical implications
 References
 

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