Syncope Flashcards
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
Syncope
Prodromal symptom of fainting “I almost fainted”
Presyncope
What causes should be at the forefront of syncope/presyncope differential?
Cardiac and Neurologic
A patient tells you they have had multiple syncopal events with a new onset. What condition should be considered?
AV block
A patient tells you they have had multiple syncopal events over many years. What condition should you be considering?
Vasovagal syncope
A patient tells you that they have multiple syncopal episodes daily lasting multiple minutes. What condition should be considered?
Psychogenic
A patient has an extended prodrome prior to their syncopal event. What should be considered?
Vasovagal syncope
A patient has no prodrome prior to their syncopal event. What cause should be considered?
Cardiac causes
A patient tells you their syncopal episodes always occur supine. What are you thinking?
Cardiac etiology
A patient tells you that syncopal episodes always occur with change in position. What are you thinking?
Orthostatic hypotension (even multiple minutes after change)
A patient tells you that they have syncopal episodes when they are standing upright. What should be considered?
Reflex syncope (vasodilation +/- bradycardia
What are provocative factors for reflex syncope?
- 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
What are possible prodrome symptoms for syncope?
- Lightheadedness
- Warmth or cold
- Sweating
- Palpitations
- Nausea- abdominal discomfort
- Blurred vision (blindness possible)
- Diminished hearing or tinnitus
- Pallor reported by observers
What are historical factors post syncopal event?
- 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
If the “syncopal episode” is actually a seizure, what would witnesses likely see?
Eyes open
If a patient has syncope in the presence of a new/severe HA, what should be ruled out?
SAH
If a patient has syncope with chest pain or shortness of breath, what should be ruled out?
PE, MI, HF
If a patient has syncope with fever, what should be done?
- Sepsis workup
- Consider COVID19 infection (this can be only symptom)
What conditions are at high risk for syncope due to arrhythmias?
- CAD
- Valvular disease
- Cardiomyopathy
- Congenital heart disease
- Previous cardiac surgery
What condition places patient at high risk for orthostatic hypotension due to autonomic neuropathy and hypoglycemia?
DM
What antibiotics medications can cause QT prolongation that can lead to syncope?
Antibiotics
* Fluoroquinolones
* Macrolides
* Trimethoprim
* Pentamidine
* Azole antifungals
What antipsychotic medications can cause long QT leading to syncope?
- Haloperidol
- Droperidol
- Thioridazine
- Pimozide
What antiemetics cause LQTS causing syncope?
- Ondansetron
- Granisetron
- Metoclopramide
What antiarrhythmics cause LQTS leading to syncope?
Class IA: Na+ channel blockers
* Quinidine
* Procainamide
* Disopyramide
Class III: K+ channel blockers
* Amiodarone
* Sotalol
* Dofetilidev
* Ibutilide
* Dronedarone
What is considered long QT in men? Women? When are you concerned for Torsades?
- Men: >440
- Women: >460
- Torsades: >500
What are concerning historical factors for cardiac etiology?
- 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%!
If BP very low on pe of syncopal patient, what should you think?
- Sepsis
- Cardiac issue
- Overdose
- Late HF
if BP very high on PE of syncopal patient, what should you consider?
- Stroke
- HF
- Anxiety
What PE should be performed on syncopal patient?
- 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
What are irregular or bradycardic rhythms that can cause syncope?
- Afib, significant PVCs
- Heart blocks (especially 3rd degree)
- Symptomatic bradycardia
What are s/s of heart failure?
- Bilateral lower extremity swelling
- Increased JVD
- S3/S4
What diagnostic tests are required for syncope work up?
- EKG
- Cardiac monitor throughout stay
What syncopal work up can be considered depending on history, age, and risk factors?
- 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
What is the disposition of syncopal patients
- 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
Do not use the canadian syncope calculator if…
- LOC >5 min
- Change in mental status
- Obvious witnessed seizure
- Major trauma/head trauma causing LOC
- Intoxication- ETOH or drugs
- Language barrier
What is the San Francisco Syncope Rule
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
What are types of reflex syncope?
- Vasovagal
- Situational
- Carotid sinus syncope
What is reflex syncope?
- Vasodilation and/or bradycardia causing systemic hypotension and cerebral underperfusion
What is the epidemiology of vasovagal syncope
MC cause of syncope in all ages
60% of patients with a heart condition and syncope diagnosed with vasovagal syncope
Presentation of vasovagal syncope
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)
PE of vasovagal syncope
No cardiac or neuro abnormalities
Workup of vasovagal syncope
- 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
Disposition of vasovagal syncope
- Evaluated with risk evaluation device
- Low risk and moderate risk may be discharged home with follow-up with primary care
- High risk admitted
What is reflex syncope?
- Failure of sympathetic efferent vasoconstrictor
