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Senior - E Med > 6 - Syncope > Flashcards

6 - Syncope Flashcards

1
Q

Syncope definition?

A

Syncope or “fainting”
Is a symptom complex consisting of a brief loss of consciousness associated with an ability to maintain postural tone that

spontaneously resolves without medical intervention

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2
Q

Near syncope?

A

Same thing but you dont loose consciousness

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3
Q

Pathophys of fainting?

A

Inciting event causing drop in CO -> decreased O2

  • 10 sec of complete disruption of blood flow
  • or reduction of cerebral perfusion by 35-50%
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4
Q

Pathophys causes of syncope?

A
  • UKN - 37%
  • Vasovagal (reflex mediated) - 21%
  • cardiac - 10%
  • Orthostatic
  • meds
  • neurologic
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5
Q

Its just fainting, why do we care?

A

Each diagnosis classification carries with it progostic risk

  • cardiac double risk of death
  • neurologic, increased death by 50%
  • UKN - death by 30%

(Compared to gen pop)

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6
Q

Death risk of vasovagal?

A

No increased death risk over “normals”

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7
Q

Most deadly type of syncope?

A

Cardiac

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8
Q

Common cardiac causes of syncope?

A 
HCM
PE
Acute MI
- if myocardial dyskinesia reduces CO
Brady and tachy dysrhythmias -> transient hypoperfusion
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9
Q

Ho do dysrhythmia induced syncope’s present?

A

Sudden and without prodromal symptoms

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10
Q

What is the largest determination of how cardiac syncope presents?

A

The autonomic nervous system’s ability to compensate for decreased CO

Degree of underlying CVD

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11
Q

___ is a form of reflex-mediated or neurally mediated syncope, is associated with inappropriate vasodilation, bradycardia or both

A

Vasovagal syncope

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12
Q

Prodrome for vasovagal syncope?

A
  • Lightheadedness
  • w/ or w/out nausea,
  • pallor
  • sweating
  • feeling of warmth
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13
Q

Slow progressive onset with associated prodrome suggests?

A

Vasovagal syncope

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14
Q

Common triggers for vasovagal syncope?

A

Aka neurally/reflux-mediated

Exposure to:

  • sight/sound
  • smell
  • fear
  • pain
  • emotional distress
  • instrumentation

Prolonged standing in heat

Situations

  • coughing
  • micturition
  • defecation
  • swallowing
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15
Q

Carotid sinus hypersensitivity, another reflex-mediated syncope is characterized by?

A

Bradycardia or hypotension

MC: abnormal vagal response -> brady and asytole >3 sec

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16
Q

Patient population for carotid sinus hypersensitivity

A

Older patients with recurrent syncope and negative cardiac evaluations

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17
Q

Why do postural changes effect syncope?

What is this called?

A

The bodies compensation methods cannot keep blood where it needs to be against gravity (volume loss, tone lass etc)

Orthostatic hypotension or postural hypotension

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18
Q

Psych and syncope?

A

Up to 40% of vasovagal
Up to 62% of unexplained

Are associated with psych problems

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19
Q

Neurologic syncope is?

A

A zebra, this condition is rare

20
Q

What conditions must be met for syncope to be considered neurologic?

A

The pt will have neurologic deficits that are transient.

They must have NO persistent neuro deficits

21
Q

What is a rare cause of brainstem ischemia caused by exercise?

A

Subclavian steal syndrome

22
Q

What happens with subclavian steel syndrome?

A

Exercise of the ipsilateral arm causes blood to shunt or be “stolen” from the vertebrobasilar system to the subclavian artery supplying the arm muscles

23
Q

PE for subclavian steal syndrome?

A

MC narrowing on L

Decreased pulse volume and diminished blood pressure in the affected arm.

24
Q

Why are seizures and syncope often confused?

A

Brief tonic-clonic movements are often associated with syncope

  • confusion (postictal)
  • tongue biting
  • incontinence
  • epileptic aura
25
Q

Subarachnoid hemorrhage and syncope?

A

Fall and head injury from syncope can be a cause of subarachnoid hemorrhage

26
Q

Common med classes that cause syncope?

A
  • ED meds
  • Anti-hypertensives
  • B-blocker
  • cardiac glycosides (digoxin)
  • anti-dysrhythmics
  • anti-psychotics
  • anti-depressants
  • anti-Parkinson’s
  • phenothiazines
  • nitrates
  • ETOH
  • Cocaine
27
Q

Goals of evaluation for syncope pts in the ED?

A

ID death risk pts

If diagnosis is made treat that

If no diagnosis

  • risk stratification
  • through PE
  • EEG
  • any other tests needed
28
Q

Red flag symptoms for syncope?

A

Chest pain
Palpitations
HA
Abdominal pain

So the same shit as everything else

29
Q

Sudden syncope event without warning and events associated with exertion raise suspicion for?

A

Cardia dysrhythmia

Structural cardiopulmonary lesion

30
Q

More than 5 syncopal episodes in 1 year is most likely?

A

More likely
- Vasovagal syncope for psych

Less likely dysrhythmia

31
Q

History questions?

A 
Drugs
Etoh 
Aggressive wt loss attempts
Fam hx (prolong QT, SCD etc)
Single car crashes (elderly)
- dont get hung up on the trauma and miss the cause
32
Q

Convulsive syncope?

A

Mild, brief, tonic-clonic activity (remember seizures are often misdiagnosed as syncope)

33
Q

Urinary incontinence?

A

Dont care, not useful in distinction

34
Q

What is the most important tool for diagnosis of syncope?

A

The history

- diagnostic tests have low diagnostic yields

35
Q

ECG and syncope?

A

Rarely leads to diagnosis but its simple and non-invasive so get one

36
Q

Lab test for syncope?

A

Based on hx

But some common ones

  • heme stool test (orthostatic)
  • CBC (orthostatic)
  • Hcg
  • look for acidosis
  • b-type natiuretic peptide or pro-b type naturietic peptide levels are predictive for morbidity
37
Q

Hyperventilation maneuver?

A

Open-mouthed, slow, deep breaths at rate of 20-30 breaths/min for 2-3 min
- may help reproduce psychiatric syncope or prodromes

38
Q

Clinical yield for CT, EEG, or LP with syncope?

A

Low

39
Q

Which syncope pts get admitted?

A

Admit:
Cardiac and neurologic

Send home:
Vasovagal, orthostatic, med induced
- just fix the problem

40
Q

Decision making and risk management, consider admission in pts with?

A
  • hx of CHF
  • abnormal ECG
  • hematocrit <30
  • dypsnea
  • SBP <90 in ED
  • syncope while supine
  • syncope during exercise
  • syncope w/out prodrome
  • palpitations prior to syncope
  • age >60

So all the cardiac shit

41
Q

Syncope flow chart?

A

Slide 35

42
Q

What tx do all the cardiac syncope pts need?

A

External defibrillators

43
Q

Considerations for elderly pts with syncope?

A
  • increased risk for bad outcomes
  • risk increases w age
  • L ventricle is less compliant
  • decreased vascular tone
  • decreased adrenergic response
  • increased pathophysiologic issues (HTN, atherosclerosis)
44
Q

Big concerns for preggo syncope?

A

Ectopic pregnancy
PE

Not so worried about cardiac

45
Q

Joker: How can you shoot women and children?!

A

Door Gunner: Easy! You just don’t lead ‘em so much! [laughs cunningly] Ain’t war Hell?! [laughs]

Senior - E Med (8 decks)

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