Syncope Flashcards
What is syncope?
Loss of conciousness due to lack of blood pressure
Causes of syncope
- Postural hypotension
- Bradycardia/tachycardia - if VF or torsade
- Structural heart disease eg aortic stenosis
- Hypertrophic cardiomyopathy
- Ion channelopathies - long QT, Brugada, ARVC
- Massive PE
Arrhythmogenic right ventricular cardiomyopathy
What to determine if LOC?
Seizure or syncope?
Syncope vs seizure
Syncope can lead to seizure - anoxic seizure
Need to keep head at same level as heart if vasovagal
Who is low risk if have syncope fall?
- Less than 50
- Vasovagal
- No CVD disease
- Normal ECG
Steps when someone presents with LOC
- History
- Witness history
- Examination
- ECG
- Investigations
What is asked in history about syncope?
- Position - found on floor, landing etc
- Action - did they break fall with arms etc?
- Tired/sleepy/jetlagged or other triggers
- Before and after events of fall
- Previous episodes
- Extended FH - did anyone die younger than they should?
- Predisposing factors eg CV disease etc?
Triggers for syncope
- Hot
- Stressed
- Anxious
- Dehydrated
- Alcohol
- Squemish eg blood
- Large meal
Predisposing factors for syncopal fall
Drugs:
* Beta blocker
* GTN
* Antihypertensives
* Tamsulosin/finasteride - profound pos hypo
* Parkinsons medication
* TCA’s
* Neuroleptics eg haloperidol
- Alcohol
- Recreational drugs
- Parkinsons
Questions to ask about what happened before syncope?
- Palpitations?
- Chest pain?
- Vertigo - inner ear/cerebellum problem
- Light headed
- Aura/smells
- Tunnel vision
- Sweating
- Hot/cold
- Nausea
- Yawning - air hunger - as HR slows
- SOB
- Cough/micturition/other valsalva
Questions to ask about after
- Do you remember falling?
- Hitting the ground?
- Remember waking up?
- Recovery time?
- Evidence of any evasive action - Guardsmans (shoulder # vs colles)
- Any incontinence, tongue biting
- Time to tonic
- Time to clonic
- Post event mental state
- Diuresis after event - sign of rapid HR
Questions to ask witness to fall
- Pale/flushed
- Eyes roll - lost cardiac output
- Pulse?
- Did they look dead?
- Confused post event? - cardiac event
- Focal seizure signs
- Sat/propped up/flat
- Position on floor when fell
Questions to ask patient about PMH
- Febrile convulsions as child
- FH epilepsy
- Faint as a child
- Does it happen in particualr environments?
- Screen cardiac RF and neuro RF
What happens in vasovagal?
- BP drops
- HR drops
- Get warning - go hot, sweaty, nauseous
- Triggered by something
- Lose conc when sat up again sometimes
- NEED TO LIE FLAT
What is vasovagal also known as?
Neurocardiogenic syncope
Signs to look for on examination if syncope
- Aortic stenosis - slow rising, low volume carotid pulse, quiet/absent S2, EJSM
- Hypertrophic cardiomyopathy
ECG findings for syncope
- Massive PE - S1, Q3, T3, RV heart strain T wave inversion V1-V3
- Sinus node disease?
- Coronary disease
- Conducting issue - LBBB etc
- Accessory pathway
- Ion channelopathies - Brugada ST elevation, long QT
- Electrolyte problems - calcium, K+, Mg low = long QT
- Assymetric T wave inversion = strain
What is TAchy Brady?
- AF to sinus rhythm
- But when go to sinus their heart stops for a few seconda
- Need pacemaker
Test if unsure if LOC was vasovagal
Tilt table test
What can we do is vasovagal is more due to HR dropping than BP when on tilt table?
Can have rate drop response permanent pace maker
What is AVRC?
Fatty fibrous tissue replaces normal cardiac tissue
Causes arrhytmias
Longer term wayss to monitor heart
24hr tape
Implantable loop recorder
Troponin leak in ruptured plaque?
Not always
What is retrograde amnesia?
Loss of memory before collapse
Signals cardiac event
Responsibility regarding DVLA and LOC
- If you are first healthcare professional it is your responsibility to tell pt they cannot drive for at least 6 months or until cause is found and treated
- Exception is vasovagal as they have warning and can pull over and postural hypotension
- You must inform DVLA if pt says they won’t and document that you have informed them always
