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Emergency Medicine > Syncope > Flashcards

Syncope Flashcards

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1
Q

Transient loss of postural tone and consciousness caused by period of inadequate cerebral perfusion. Episodes rarely last >1 minute. Full recovery to baseline mental status without resuscitation, no postictal state

A

Syncope

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2
Q

Prodromal symptom of fainting “I almost fainted”

A

Presyncope

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3
Q

What causes should be at the forefront of syncope/presyncope differential?

A

Cardiac and Neurologic

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4
Q

A patient tells you they have had multiple syncopal events with a new onset. What condition should be considered?

A

AV block

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5
Q

A patient tells you they have had multiple syncopal events over many years. What condition should you be considering?

A

Vasovagal syncope

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6
Q

A patient tells you that they have multiple syncopal episodes daily lasting multiple minutes. What condition should be considered?

A

Psychogenic

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7
Q

A patient has an extended prodrome prior to their syncopal event. What should be considered?

A

Vasovagal syncope

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8
Q

A patient has no prodrome prior to their syncopal event. What cause should be considered?

A

Cardiac causes

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9
Q

A patient tells you their syncopal episodes always occur supine. What are you thinking?

A

Cardiac etiology

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10
Q

A patient tells you that syncopal episodes always occur with change in position. What are you thinking?

A

Orthostatic hypotension (even multiple minutes after change)

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11
Q

A patient tells you that they have syncopal episodes when they are standing upright. What should be considered?

A

Reflex syncope (vasodilation +/- bradycardia

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12
Q

What are provocative factors for reflex syncope?

A
  • Immediately after exercise
  • Defecation or urination
  • Coughing or swallowing
  • Post-prandial
  • Warm and crowded place
  • Prolonged standing
  • Fear, sight of blood, stress
  • Abrupt neck movements
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13
Q

What are possible prodrome symptoms for syncope?

A
  • Lightheadedness
  • Warmth or cold
  • Sweating
  • Palpitations
  • Nausea- abdominal discomfort
  • Blurred vision (blindness possible)
  • Diminished hearing or tinnitus
  • Pallor reported by observers
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14
Q

What are historical factors post syncopal event?

A
  • Continued nausea, pallor, diaphoresis with Reflex syncope
  • True syncope usually 1-2 minutes at most as supine position restores cerebral perfusion
  • Extended syncope- think seizure vs psychogenic
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15
Q

If the “syncopal episode” is actually a seizure, what would witnesses likely see?

A

Eyes open

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16
Q

If a patient has syncope in the presence of a new/severe HA, what should be ruled out?

A

SAH

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17
Q

If a patient has syncope with chest pain or shortness of breath, what should be ruled out?

A

PE, MI, HF

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18
Q

If a patient has syncope with fever, what should be done?

A
  • Sepsis workup
  • Consider COVID19 infection (this can be only symptom)
19
Q

What conditions are at high risk for syncope due to arrhythmias?

A
  • CAD
  • Valvular disease
  • Cardiomyopathy
  • Congenital heart disease
  • Previous cardiac surgery
20
Q

What condition places patient at high risk for orthostatic hypotension due to autonomic neuropathy and hypoglycemia?

A

DM

21
Q

What antibiotics medications can cause QT prolongation that can lead to syncope?

A

Antibiotics
* Fluoroquinolones
* Macrolides
* Trimethoprim
* Pentamidine
* Azole antifungals

22
Q

What antipsychotic medications can cause long QT leading to syncope?

A
  • Haloperidol
  • Droperidol
  • Thioridazine
  • Pimozide
23
Q

What antiemetics cause LQTS causing syncope?

A
  • Ondansetron
  • Granisetron
  • Metoclopramide
24
Q

What antiarrhythmics cause LQTS leading to syncope?

A

Class IA: Na+ channel blockers
* Quinidine
* Procainamide
* Disopyramide

Class III: K+ channel blockers
* Amiodarone
* Sotalol
* Dofetilidev
* Ibutilide
* Dronedarone

25
Q

What is considered long QT in men? Women? When are you concerned for Torsades?

A
  • Men: >440
  • Women: >460
  • Torsades: >500
26
Q

What are concerning historical factors for cardiac etiology?

A
  • Absence of prodrome
  • Event during exertion or supine
  • Associated with chest pain
  • Family history of sudden death
  • Known structural heart disease
  • Abnormal rhythm history

1 year mortality with cardiac syncope = 30%!

27
Q

If BP very low on pe of syncopal patient, what should you think?

A
  • Sepsis
  • Cardiac issue
  • Overdose
  • Late HF
28
Q

if BP very high on PE of syncopal patient, what should you consider?

A
  • Stroke
  • HF
  • Anxiety
29
Q

What PE should be performed on syncopal patient?

A
  • ABCs, vital signs
  • Complete cardiac exam for murmurs, irregular or bradycardiac rhythms, signs and symptoms of heart failure
  • Complete neurologic exam: mental status, cranial nerves, motor strength, sensation, gait, reflexes, finger to nose, heel to shin, romberg, pronator drift
  • Irregular neuro exam –> CT of brain
  • Evaluate for head and neck trauma if appropriate
  • Skin turgor/oral mucosa/volume status
  • Abdominal exam for AAA or rectal exam for GI bleed
  • Any other historically indicated exam
30
Q

What are irregular or bradycardic rhythms that can cause syncope?

A
  • Afib, significant PVCs
  • Heart blocks (especially 3rd degree)
  • Symptomatic bradycardia
31
Q

What are s/s of heart failure?

A
  • Bilateral lower extremity swelling
  • Increased JVD
  • S3/S4
32
Q

What diagnostic tests are required for syncope work up?

A
  • EKG
  • Cardiac monitor throughout stay
33
Q

What syncopal work up can be considered depending on history, age, and risk factors?

A
  • CT brain w/o contrast if head trauma >65, blood thinners, concern for skull fracture, focal neuro def
  • CBC if poss infection, anemia
  • Troponin: if considering admission
  • D Dimer: if concerned for PE and cannot PERC out (CTA of chest with IV contrast if high risk patient
  • CXR
  • Orthostatics
  • FOBT: dark stools, anemia on CBC, cancer hx
  • HCG: ectopic (any child bearing age female with intact uterus)
  • UDS
34
Q

What is the disposition of syncopal patients

A
  • Admission allows for cardiology and neurology consult within 24 hours
  • Consider Risk stratification tool to see outpatient vs inpatient: Canadian Syncope Risk Score or San Francisco Syncope Rule
35
Q

Do not use the canadian syncope calculator if…

A
  • LOC >5 min
  • Change in mental status
  • Obvious witnessed seizure
  • Major trauma/head trauma causing LOC
  • Intoxication- ETOH or drugs
  • Language barrier
36
Q

What is the San Francisco Syncope Rule

A

5 predictors of high risk for serious outcomes at 7 or 30 days
1. CHF history
2. Hct ,30%
3. ECG or cardiac monitoring abnormal
4. SOB history
5. SBP <90 mmHg at triage

CHESS

37
Q

What are types of reflex syncope?

A
  • Vasovagal
  • Situational
  • Carotid sinus syncope
38
Q

What is reflex syncope?

A
  • Vasodilation and/or bradycardia causing systemic hypotension and cerebral underperfusion
39
Q

What is the epidemiology of vasovagal syncope

A

MC cause of syncope in all ages
60% of patients with a heart condition and syncope diagnosed with vasovagal syncope

40
Q

Presentation of vasovagal syncope

A

Prodrome usually present
* Pale skin
* Nausea
* Feeling warm
* Cold sweat
* Blurred vision

  • Classic presentation: donating or seeing blood, emotional upset
  • After vigorous exercise in athletes
  • In sitting or standing position
  • Post episode fatigue possible (but not in cardiac induced)
41
Q

PE of vasovagal syncope

A

No cardiac or neuro abnormalities

42
Q

Workup of vasovagal syncope

A
  • EKG: usually normal or non-specific
  • Strong history: episode + previous medical history
  • Other investigations as indicated from history
  • Often diagnosis of exclusion after careful history and negative workup
43
Q

Disposition of vasovagal syncope

A
  • Evaluated with risk evaluation device
  • Low risk and moderate risk may be discharged home with follow-up with primary care
  • High risk admitted
44
Q

What is reflex syncope?

A
  • Failure of sympathetic efferent vasoconstrictor

Emergency Medicine (13 decks)

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