Syncope Flashcards
Syncope
- Transient, sefl-limited loss of consciousness due to acute global impairment of cerebral blood flow for 6-8 seconds
- Rapid, brief, spontaneous recovery
(aka: “passing out”, “falling out”, “fainting”, “blackout”)
Syncope: high risk features
- History of chest pain or EKG shows ischemia
- Heart: failure, structural defect
- Long QT
- interventricular conduction delay
- family Hx: sudden death
- palpitations in time of syncopal event
- syncope during exercise or at rest
Syncope prevalence and cost
3% ER visits (1% of all hospital admissions)
35% lifetime
MC between 10-30 yrs & after 70
Vascular causes of syncope
- Cardiogenic
- CVA
- Volume depletion
Infectious causes of syncope
- Shock
- Sepsis
- Meningitis
Psychogenic cause of syncope
- Fair
- Disgust
Three most common causes of syncope
- Neurologic
- Orthostatic
- Cardiac
Define neurologic syncope
Related to pathological changes to happen within the autonomic nervous system → signal medulla to decreases blood pressure and heart rate → decrease in cerebral blood flow to brain
(relies on intact ANS)
MC causes of neurally mediated syncope
- Vasovagal (MC)
- Pulmonary (cough, wind-instrument player, the “fainting game”)
- Urogenital (micturition syncope)
- GI (swallow syncope, defication)
- Cardiac (outflow obstruction)
- Carotid sinus sensitivity
- Ocular (sudden IOP increase)
Orthostatic-mediated syncope is due to the body’s inability to ______
maintain blood pressure after standing or sitting up (HR doesn’t increase despite hypotension)
Orthostatic hypotension is a reduction and systolic blood pressure of at least ____ mm Hg or diastolic blood pressure of at least ____ mm Hg w/in 30 minutes of standing or head tilt on a tilt table.
20
10
Types of orthostatic-mediated syncope (4)
- Autonomic failure (primary or secondary)
- Postprandial hypotension
- Drug (Iatrogenic)
- Volume Depletion
Peripheral neuropathies that can cause Secondary autonomic failure → orthostatic mediated syncope (5)
- Amyloidosis
- Diabetes
- HIV neuropathy
- Sjogren’s
- Paraneoplastic autonomic neuropathy
(There are also hereditary sensory and autonomic neuropathies)
Primary autonomic failure (orthostatic mediated syncope) is due to _______ (2 conditions).
- Lewy Body Disease
- Multiple system atrophy
Medications for orthostatic-mediated syncope (4)
- Fludrocortisone
- midodrine
- dihydroxyphyenlserine
- pseudoephedrine
(2nd line: Pyridostigmine, vohmbine, desmopressin, erythropoietin)
Cardiac-mediated syncope is due to ______ or ______ issue that prevents blood from perfusing the brain.
- structural
- electrical
(all are high risk!!)
Cardiac syncope: arrhythmias causes (4)
- Sinus node dysfunction
- AV node dysfunction
- Supraventricular tachycardia
- Inherited channelopathy
Cardiac-mediated syncope: structural causes (4)
- Valve disease
- Obstructive cardiomyopathies
- Atrial Myxoma (tumor)
- Pericardial effusions or tamponade
(obstruction or its being squeezed)
How do you evaluate a patient for cardiac syncope (6)?
- Hx of arrhythmia
- Hx of palpitations or chest pain w/syncope
- Known structural heart disease
- Rx review
- EKG
- Echo
It takes a ventricular heart rate above ____ or below ____ to cause syncope
- 200
- 40
You must differentiate syncope from _____.
seizure
(patients will confuse these, key difference = time to recovery)
Neurally-mediated syncope is due to ________ autonomic activation/autonomic failure. Orthostatic syncope is due to ________ (autonomic activation/autonomic failure).
- Neurally: autonomic activation
- Orthostatic: autonomic failure
If a patient has a family history of syncope, they are at risk of developing ______-mediated syncope.
neurally
What is the biggest difference between seizure and neurally-mediated syncope?
confusion quickly resolves after neurally-mediated syncope episode
Symptoms during a neurally-mediated syncope event (5).
- myoclonic movement/jerks
- eyes open & deviate upward
- dilated pupils
- roving eyes
- urinary incontinence
Myoclonic movements/jerks are seen in both neurally-mediated syncope and seizures. What is the distinction?
- neurally-mediated: arrhythmic & multifocal
- seizures: rhythmic & focal
Autonomic symptoms seen in neurally-mediated syncope (6).
- diaphoresis
- hyperventilation
- nausea
- pallor
- palpitations
- yawning
Coat-hanger headache is seen in ______-mediated syncope.
orthostatic
Supine hypertension is commonly seen in ______-mediated syncope.
orthostatic (50% of patients w/autonomic failure)
Visual blurring or blacking out is commonly seen in ______-mediated syncope.
orthostatic
define pre-syncope
light-headedness/dizziness
(usually response to position change that precedes orthostatic-mediated syncope)
Medications for cardiac-mediated syncope (2)
- beta blocker
- anti-arhythmics
What are the general differences in syncope management (between orthostatic, cardiac and neural)?
- Orthostatic: behavior & underlying disease
- Cardiac: surgery & meds
- Neural: hydration & maneuvers
Behavioral modifications to treat ortho-static mediated syncope (4)
- salt diet
- teach them to get up slowly
- elevate head of bed
- control underlying disease
(also medication)
Isometric counter-pressure is used to treat ______-mediated syncope and vagal maneuvers are used to treat ______-mediated syncope.
- neurally
- cardiac
Other than medication, what is the treatment for neurally-mediated syncope (3)?
- isometric counter-pressure (knees to chest)
- crossed legs, flexed arms
- IV hydration
What are the procedures used to treat cardiac-mediated syncope (4)?
- cardioversion
- valve replacement
- ablation
- pacemaker implantation
