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The Elderly Patient > Syncope > Flashcards

Syncope Flashcards

1
Q

Definition of syncope

A
  • Transient, self-limited LOC
  • Onset rapid
  • Recovery spontaneous, complete, and usually prompt
  • Transient global cerebral hypo-perfusion (brain not getting enough oxygen)
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2
Q

Explain cerebral auto-regulation & syncope

A
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3
Q

Classification of syncopal disorders

A

Real or apparent loss of consciousness

Syncope

  • Neurally-mediated reflex syncopal syndromes
  • Orthostatic
  • Cardiac arrhythmias
  • Structural cardiac or cardiopulmonary disease
  • Cerebrovascular – steal syndromes

Non-syncopal

  • Disorders resembling syncope with impairment or loss of consciousness (e.g. seizures)
  • Disorders resembling syncope without impairment or loss of consciousness (e.g. psychogenic syncope)
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4
Q

Epidemiology of syncope

A
  • Prevalence adults >17yrs old approx 10%
  • Lifetime risk up to 70 years approx 42%
  • 3-5% ED attendances
  • 1-3% hospital admissions
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5
Q

Mortality link with syncope

A
  • Excessive mortality
    • Left ventricular failure
    • Hypertrophic cardiomyopathy
    • Aortic stenosis
    • Previous ventricular arrhythmia
  • No increased mortality
    • Young patients without heart disease & normal ECG
    • Neurally mediated syndromes
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6
Q

Explain reflex mediated syncope

A
  • Mostly vasovagal syncope
  • Carotid sinus syndrome (pressure on carotid sinus cause syncope)
  • Situational syncope - cough (excess cough too high inter-thoracic pressure = syncope), micturition (bladder contracts = syncope), defaecation, brass instrument players, adolescent stretch (stretch arms = syncope)
  • Any age
    • Mostly in younger people and grow out
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7
Q

Explain orthostatic hypotension

A
  • Fall of SBP>20mmHg or DBP>10mmHg within 3 minutes of standing
  • Cause:
    • Drugs (medication e.g. anti-hypertensives, anti-depressants, anti-psychotics)
    • Autonomic failure (e.g. diabetic neuropathy)
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8
Q

Cardiac causes of syncope

A
  • Arrhythmia – CHB, VT.
  • Structural cardiac disease
    • Aortic stenosis
    • Cardiomyopathy
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9
Q

When is misdiagnosis of syncope?

A
  • Community and secondary care epilepsy patients
  • 30% misdiagnosis
  • “Receiving treatment that doesn’t work and which fails to control a condition they don’t have”
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10
Q

Initial evaluation of syncope & questions

A
  • Is loss of consciousness attributable to syncope or not?
  • Is heart disease present or absent?
  • Are there important clinical features in the history that suggest the diagnosis?

Questions about circumstances just prior to attack

  • Position - supine, sitting, standing
  • Activity - rest, change in posture, during or after exercise, during or immediately after urination, defaecation, cough or swallowing
  • Predisposing factors - crowded or warm places, prolonged standing, post-prandial
  • Precipitating events - fear, intense pain, neck movements

Questions about onset of attack

  • Nausea, vomiting, abdominal discomfort
  • Feeling of cold, sweating, aura, pain in neck or shoulders, blurred vision

Questions about attack (eyewitness)

  • Skin colour - pallor, cyanosis
  • Duration of loss of consciousness
  • Movements and their duration
  • Tongue biting
  • Urine incontinence (can happen in syncope and epilepsy)

Questions about end of attack

  • Sweating, feeling of cold, nausea
  • Confusion, focal neurology
  • Skin colour
  • Injury
  • Chest pain, palpitations

Questions about background

  • Family history of sudden death (especially under 40), congenital arrhythmogenic heart disease or fainting
  • Previous cardiac disease
  • Neurological history
  • Metabolic disorders
  • Medication (hypotensive, antiarrhythmic, and QT prolonging agents → longer than 500ms = ventricular arrhythmias)
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11
Q

What looking for in examination of syncope?

A
  • Signs of cardiac failure/murmurs
  • Neurological evaluation
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12
Q

Investigations in syncope

A

The most important investigation is a 12 lead ECG

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13
Q

Telling the difference between right and left bundle branch block

A

Right bundle = V6 has S wave

Left bundle = V1 has S wave

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14
Q

Left vs right axis deviation

A

Left axis deviation = Lead 1 and 2 away from each other

Right axis deviation = Lead 1 and 2 towards each other

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15
Q

What is wrong?

A

QT prolongation (cause by hypomagnesium, hypocalcaemia, hypokalaemia)

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16
Q

What is wrong with ECG?

A

Shortened PR interval and axis deviation

Wolf-Parkinson White syndrome

17
Q

What is wrong with this ECG?

A

ST elevation

18
Q

When to hospitalise a patient with syncope?

A
  • Significant heart disease
  • ECG abnormalities
  • Syncope during exercise
  • Severe injury
  • Family history of sudden death
  • Syncope in supine position
  • Frequent recurrent episodes
  • High suspicion of cardiac arrhythmia
  • Stroke/focal neurology

The Elderly Patient (9 decks)

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