Syncope Flashcards
Patient words for Syncope
- Loss of Consciousness
- Passing Out
- Fainting
- Falling Out
This is the term for abrupt, transient, complete loss of consciousness that occurs due to a period of insufficient cerebral perfusion. The loss of consciousness is typically brief and is followed by complete, rapid spontaneous recovery.
Syncope
This is the term for an alert cognitive state in which one is aware of oneself and situation.
Consciousness
What does consciousness refer to in reference to physiology?
- Organized Cortical Activity
- Adequate supply of oxygen and glucose
This is the term for the feeling of lightheadedness as if one may faint.
Pre-Syncope
How should you approach pre-syncope (especially in the elders)?
Evaluate as if it was actually syncope.
T/F: Syncope is a common complaint in the ED, accounting for 10-30% of all hospital admissions.
False! This was pretty basic, you should know it’s 1-3%. Feel embarrassed.
But it is still a common complaint in the ED with 3-5% :)
T/F: Syncope can be a manifestation of a multitude of dz processes, some quite serious. However, it is often benign and self-limited.
True
What are the three classifications of Syncope?
- Neurally-Mediated Syncope (~58%)
- Cerebrovasclar Disease
- Cardiopulmonary Diseases
This is the most common cause of syncope, accounting for 25-65% of cases. Most importantly discovered in retrieving a history.
Neurocardiogenic Syncope (Vasovagal)
Classification: Neurally Mediated Syncope
This is a variant of vasovagal syncope. Usually caused by post-tussive, post-micturition, GI-stimulated, Psych, etc. Most importantly discovered in retrieving a history.
Situational Syncope
Classification: Neurally Mediated Syncope
This is a type of syncope that occurs when orthostatic hypotension is the underlying problem. Commonly assc with DM, EtOH, Advanced Age, Medications, etc. Most importantly discovered in retrieving a history, PE, med review, EKG, or appropriate labs.
Autonomic Failure
Classification: Neurally Mediated Syncope
This is a type of syncope that is most common in elderly patients with atherosclerosis. Most importantly discovered in performing a carotid sinus massage or compression of the sinus.
Carotid Sinus Sensitivity
Classification: Neurally Mediated Syncope
This type of syncope is usually from rupture of a berry aneurysm or AV malformation. It presents with a severe acute headache. Possibly a THUNDERCLAP. Followed by a syncopal episode.
Subarachnoid Hemorrhage
Classification: Cerebrovascular Dz
If suspecting a subarachnoid hemorrhage, what do you do next?
Non-contrast Brain CT and/or Lumbar Puncture
This type of syncope is caused by retrograde vertebral artery flow assc with transient neurologic symptoms related to cerebral ischemia. Commonly presents with pain and fatigue in the affected upper extremity, coolness, paresthesia, dizziness, vertigo, syncope, and/or nystagmus.
Subclavian Steal Syndrome
Classification: Cerebrovascular Dz
What can cause the retrograde vertebral artery flow in Subclavian Steal Syndrome?
- Proximal Subclavian Artery Stenosis
- Proximal Subclavian Artery Occlusion
How would you move forward if you suspect Subclavian Steal Syndrome in a patient?
- Check BP and Distal Pulses in BOTH arms
- Duplex US
- MRA
This type of syncope is caused by ischemia or infarct.
Ischemia/Infarct :D
Classification: Cardiopulmonary Dz
This type of syncope is caused by arrhythmia.
Arrhythmia :D
Classification: Cardiopulmonary Dz
This type of syncope is caused by pulmonary emboli.
Pulmonary Emboli :D
Classification: Cardiopulmonary Dz
Management of suspected Pulmonary Emboli due to syncopal episode?
- Spiral CT
- Pulm Angiography
- D-dimer?
Management of suspected Ischemia/Infarct due to syncopal episode?
- EKG
- Cardiac Enzymes
- Stress Test
- Cardiac Cath
Management of suspected Arrhythmia due to syncopal episode?
- Identify if Tachy, Brady, AV Block, Long QT, etc.
- EKG
- Holter Monitor
This type of syncope is caused by structural abnormalities.
Structural Abnormality :D
Classification: Cardiopulmonary Dz
This type of syncope is cause by cardiac tamponade.
Cardiac Tamponade :D
Classification: Cardiopulmonary Dz
Management of suspected Cardiac Tamponade due to syncopal episode?
- Physical Exam
- EKG
- CXR
- Echo
Management of suspected Structural Abnormality due to syncopal episode?
- Physical Exam
- Echo
Looking for:
A. Aortic Stenosis
B. HCM/HOCM
T/F: Non-Syncopal Loss of Consciousness should not be included in your differential diagnoses for a patient with syncopal or pre-syncopal incident.
False, they should be! #BASIC #pH10
Common causes of Non-Syncopal Loss of Consciousness
- Sz
- Head Trauma
- Metabolic Factors
***Although they have lost consciousness, it may not be due to insufficient cerebral perfusion.
Approximately ___ of individuals are likely to experience a syncopal episode in their lifetime.
1/3
As we age, the risk for syncopal episodes increase. According to a study, at what age is there a sharp rise in the incidence of syncopal episodes? What sex is more affected?
Age 70; Women
Is cardiac related syncope more common in men or women?
Non-cardiac related syncope?
Unknown cause of syncope?
Men; Women; Women
Pathophysiology of Syncope
Transient inadequate cerebral perfusion
Risk Factors for Syncope
- Age
- CV Dz
- Hx of CVA or TIA
- HTN
- Low BMI
- Inc. EtOH intake
- DM
T/F: An etiology can be identified in approximately 50% of syncope cases using history, PE, and EKG.
True
Important things to investigate in History of a Syncopal Patient
- PMH of Cardiac Dz
- Number of Syncopal Episodes
- Circumstances surrounding episode of syncope
- Assc Symptoms
- Pre-syncopal Symptoms
- Duration of Symptoms
- Other PMH
- Medications
- Drug/EtOH Use
- ROS
- Social and Family Hx
Don’t use leading questions; Get witness reports if possible
Important things to investigate in Physical Exam of a Syncopal Patient
- VITAL SIGNS (include orthostatics)
- Cardiac Exam (including Valsalva)
- Pulmonary Exam
- Neck Exam
- Neurologic Exam
- Rectal for Occult Blood
- Others per pt presentation
Important things to investigate in Labs/Testing of a Syncopal Patient
- CBC
- BMP/CMP
- Tox Screen
- Cardiac Enzymes
- EKg
- Carotid Sinus Massage
- Tilt Table Testing
- CT Brain
- EEG
- Carotid US
- Others per pt presentation
Tx of Syncope
Dependent on the underlying cause!!
- Cardiac causes
- - Arrhythmias may require cardioversion, medications for long term control, pacemaker implantation
- - Structural deficits may require surgery - Orthostatic hypotension
- - IV rehydration, discontinue medications that are exacerbating the condition - Neurally mediated
- - Require reassurance, educating the patient regarding the circumstances causing the syncope, avoidance of triggers - Psychiatric
- - Antidepressants, anxiolytics, avoidance of triggering events, therapy - Neurologic
- -SAH may require surgery
T/F: Patients with Cardiac Syncope are at a low risk for sudden death.
False, they are at a significant risk (Greater if they have CHF too)
This type of syncope is common in young patients with no cardiac diseases. Typically they present with multiple episodes.
Psychiatric Syncope
T/F: Hypoglycemia and hypoxia more often result true syncope.
False: They more often result in stupor or coma rather than true syncope.
Approximately 5-15% of patients thought to have syncope actually have a seizure disorder.
Good to know! It is difficult to determine the difference sometimes. Some Szs don’t have convulsions, some syncope have convulsive episodes. #Sigh
Factors that suggest a sz:
- Prodrome (aura)
- Episode of abrupt onset with assc. injury
- Presence of tonic phase before the rhythmic clonic activity.
- Head deviation or unusual posturing during the episode
- Tongue biting (lateral aspect)
- Loss of bowel or bladder control
- Postictal phase
