19. Fall/collapse Flashcards
San Francisco Syncope Rules.
a) Predicts what?
b) Criteria: CHEST
c) Score and management
a) Risk of serious outcomes in the 7 days post-syncope or near-syncope
b) CHEST: C - Cardiac failure H - Haematocrit < 30% E - ECG abnormal S - Systolic BP < 90 T - Tachypnoeic (SOB)
c) If > 0, admit for observation
Blackouts.
a) Define ‘syncope’
b) Main causes of ‘blackout’
a) Transient global hypoperfusion causing TLOC, characterised by a rapid onset, short duration and spontaneous complete recovery.
(excludes seizures, coma, shock or other states of altered consciousness)
b) - Neurally-mediated: vasovagal syncope, carotid sinus hypersensitivity, situational syncope
- Postural (orthostatic) hypotension.
- Cardiac abnormalities (arrhythmias, structural e.g. LVOT obstruction like AS)
- Neurological: epilepsy, hypoglycaemia, alcohol, drugs,
Blackouts: assessment
a) History (inc HPC, PMHx, FHx, DHx)
b) Bedside tests
c) Bloods
d) Imaging
e) Special tests
a) - Documenting details of the event, from the patient and a witness if possible: before (eg chest pain, sweaty), during (eg shaking, incontinence, duration, head injury), after (eg confusion, recovery time)
- PMHx of previous blackouts/diseases that could cause (DM, epilepsy, cardiac disease)
- FHx of cardiac disease/sudden cardiac death
- DHx: Medication that may have contributed to the blackout (eg. antihypertensives)
b) - Assessment of vital signs
- Measurement of lying and standing blood pressure (> 20/10 drop significant)
- 12-lead ECG.
c) FBC (anaemia, bleeding, infection), glucose (hypo), troponins if cardiac chest pain
d) If head injury suspected - CT head
e) - Tilt test (repeat vasovagals)
- EEG (epilepsy suspected)
- Echo - heart failure, valve dysfunction
- Angio - MI, subclavian steal
Vasovagal syncope
a) Give the 3 Ps that suggest a vasovagal cause.
b) When to use tilt test?
c) What other test may be used?
d) Score for likelihood of serious cause
e) Management - conservative
a) - Prolonged standing or sitting (vs. postural - upon standing).
- Precipitating factors — such as pain or a medical procedure.
- Prodromal symptoms — such as sweating or feeling warm/hot before the blackout.
b) For people with recurrent/severe vasovagal syncope to assess if there is a cardio-inhibitory component (eg bradycardia or asystole)
c) Implantable loop recorder
d) San Francisco rule: CHEST
e) - When prodromal symptoms come on: Lie flat with legs raised, or sit and repeatedly cross legs and tense arms
- Avoid situations that provoke syncope
- Stay hydrated
Cardiogenic syncope.
a) Features making this more likely (history, examination, investigations)
b) Management
a) - ECG abnormality
- Evidence of heart failure
- Blackouts occurring during exertion
- Palpitations/ CP/ SOB before loss of consciousness
- Family history of sudden cardiac death in people aged younger than 40 years / inherited cardiac condition
- New or unexplained breathlessness/ new murmur.
b) Referral for urgent cardiology assessment; management dependent on cause (e.g. pacemaker, ICD, rate/rhythm control, valve replacement)
- Possible tests: ambulatory ECG/ cardiac monitoring, exercise ECG testing
- No driving until assessment
- Avoid potentially dangerous activities (e.g. swimming unsupervised, climbing ladders)
Epileptic blackout.
a) Features before, during and after
b) Management
a) - Before: prodromal déjà vu, jamais vu, or other aura
- During: bitten tongue, head-turning to one side during the blackout, loss of bowel and bladder control, unusual posturing, prolonged limb-jerking
- After: confusion following the event
b) Referral for neurology assessment
- No driving until assessment
- Avoid potentially dangerous activities (e.g. swimming)
Orthostatic hypotension.
a) 1, 2, 3 rule
b) Management - lifestyle, drugs
a) Drop of 10 systolic or 20 diastolic within 3 minutes after standing
b) - First sitting when going from a supine to a standing position.
- Eating frequent, small meals to lessen postprandial blood pressure falls.
- Increase dietary salt intake (unless hypertensive).
- Drink strong tea or coffee.
- Drink at least 2 litres of water a day.
- Avoid alcohol.
- Tilting the head of the bed up during the night
- Constipation should be treated
- Stop any offending medications
- If resistant to conservative measures, consider fludrocortisone (side effect: hypokalaemia)/ midodrine
Subclavian steal syndrome.
a) What is it?
b) How does it present?
c) Causes/risk factors
d) Management
a) Stenosis of the subclavian artery on one side, causing reduced blood flow to the arm and neurological deficit. To compensate, there are collateral flows from the vertebral artery, which reduces cerebral perfusion causing syncope
b) - Syncope and/or arm weakness or other deficit, usually with arm exercise.
- Differences in blood pressure or pulse in the two arms
c) CV risk factors - smoking, diabetes, etc.
d) - Angiography to confirm stenotic vessel
- Antiplatelet therapy and statin
- Surgical - angioplasty/bypass if required
Carotid sinus hypersensitivity.
a) Possible triggers of syncopal episode
a) Head turning, neck pressure, tight collars, shaving
Ruptured AAA.
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Unruptured AAA.
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