From the Guidelines
The patient should be immediately evaluated for the cause of syncope and underlying laboratory abnormalities, with a focus on addressing potential volume depletion and anemia. The patient's presentation of a syncopal episode with mild anemia (low RBC count of 3.45 and hematocrit of 32.9%), mild hyponatremia (sodium 131 mEq/L), and elevated BUN (23 mg/dL) requires prompt attention. The patient should be placed on cardiac monitoring, receive intravenous fluids (normal saline at 100-125 mL/hr initially), and undergo further diagnostic testing including orthostatic vital signs, ECG, and cardiac enzymes, as recommended by the 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope 1. The anemia should be investigated with iron studies, B12, folate levels, and reticulocyte count, considering the potential for iron deficiency anemia, as suggested by the British Society of Gastroenterology guidelines for the management of iron deficiency anaemia in adults 1. The mild hyponatremia and elevated BUN suggest possible volume depletion, which may have contributed to the syncope, and fluid resuscitation via oral or intravenous bolus is recommended in patients with syncope due to acute dehydration 1. The normal bilirubin indicates that hemolysis is unlikely to be the cause of anemia. The patient should be kept NPO until the risk of aspiration is assessed, especially if recurrent syncope is a concern. Neurological evaluation including carotid sinus massage (if no contraindications) and possibly tilt-table testing may be warranted if cardiac causes are ruled out. The underlying cause of syncope must be identified and treated specifically, as this presentation could result from cardiac arrhythmias, orthostatic hypotension, vasovagal response, or other conditions. It is essential to consider the patient's overall clinical context, including potential chronic kidney disease, as suggested by the elevated BUN, and to evaluate for iron deficiency anemia, as recommended by the European consensus on the diagnosis and management of iron deficiency and anaemia in inflammatory bowel diseases 1. However, the most recent and highest quality study, the 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope 1, should guide the initial management of the patient's syncope.
From the Research
Syncopal Episode and Laboratory Results
The patient presented with a syncopal episode and laboratory results showing:
- RBC: 3.45
- Hematocrit: 32.9
- Sodium: 131
- Chloride: 95
- BUN: 23
- Bilirubin total: 0.2
Anemia Evaluation
According to 2, anemia is a common condition that can be detected through laboratory evaluation, including a complete blood cell count (CBC). The patient's low RBC and hematocrit levels suggest anemia. Further evaluation, such as a peripheral blood smear, reticulocyte count, and iron panel, may be necessary to determine the cause of anemia.
Reticulocyte Hemoglobin Content
Studies 3 and 4 suggest that reticulocyte hemoglobin content (CHr) can be a useful indicator of iron availability and an early marker of iron-deficient erythropoiesis. CHr can help diagnose iron deficiency and iron deficiency anemia, and monitor iron therapy. However, there is no standardized cutoff point for CHr, and different researchers use varying cutoff values.
Iron Deficiency Anemia Treatment
A study 5 compared the effects of oral lactoferrin and ferrous sulfate supplementation on iron-deficiency anemia. The results showed that lactoferrin supplementation had better effects on serum iron, ferritin, and hemoglobin concentration, but a reducing effect on fractional iron absorption and IL-6 levels compared with ferrous sulfate.
Dehydration
Although the patient's laboratory results do not directly indicate dehydration, a study 6 discusses the importance of understanding clinical dehydration and its treatment. Dehydration can be caused by a combination of physiological and disease processes, and its diagnosis requires an appraisal of the patient and laboratory testing.
Possible Causes of Syncopal Episode
The patient's syncopal episode may be related to anemia, dehydration, or other underlying conditions. Further evaluation and testing, such as those mentioned in 2 and 3, may be necessary to determine the cause of the syncopal episode and develop an appropriate treatment plan.