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Nayla Foundations > Syncope > Flashcards

Syncope Flashcards

1
Q

What is syncope

A

sudden transient LOC and postural tone with spontaneous recovery
self limited, rapid onset
spontaneous complete recovery without intervention

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2
Q

What are some pre-syncopal symptoms

A 
extreme light-headed/dizzy 
Tunnel vision
Graying out
Altered consciousness
Palpitations
Generalized weakness
Tremulousness
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3
Q

What are the causes of TRUE syncope

A 
Neurally mediated (vasovagal, situational, carotid sinus syndrome) 
Orthostatic (drug induced, ANS failure)
**Cardiac arrhythmia (brady, tachy, long QT syndrome)
Structural cardio-pulmonary
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4
Q

What are some differentials for true syncope

A 
**Somatization disorder (pseudo-syncope)
Seizure
Sleep disorder
Trauma/concussion
Hypoglycemia
Hyperventilation
POTS
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5
Q

What are key points to inquire about on history s/p syncopal episode

A

Get as many details about event (witnessed? what happened during? change in position exertion? CP? prior episodes?)
Distinguish form possible seizure
H/o cardiac disease? CVA/TIA? diabetes?
Fix of CAD? sudden death? syncope? seizures? arrhythmias?
–Cyanosis? tonic clonic? urine incontinent? tongue biting? post-octal confusion? duration?

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6
Q

What meds are important to inquire about

A 
anti-HTN/depressive/anginals 
analgesica/narcotics
muscle relaxers
anti-arrhythmatics
anti-ED
alcohol
recreational drugs
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7
Q

What can occur during the prodrome of a syncopal episode

A 
uneasiness/apprehension
visual blurring
CP/SOB (cardiac syncope)
HA/focal neuro Sx
Vasovagal (light headed, facial pallor, diaphoresis, nausea)
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8
Q

What should you assess for on physical exam s/p syncope

A

pallor vs cyanosis
orthostasis (+ if 20+ drop in SBP or 10+ drop DBP 3 minutes after supine to standing)
abn rhythm, murmur, PMI, carotid brutis
MSE (assess LOC)
pupils, EOM, facial symmetry, tongue midline
imbalance/incoordination (cerebellar dysfunction)

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9
Q

What diagnostic studies would be good to get for syncopal suspicion

A

CBC, CMP, trop
ECG (holter monitor?)
Echo (if with risk factors)
Additional workup if CV abnormality or arrhythmia suspected (Echo, Holter, external loop recorder, external patch, mobile telemetry, ICD)

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10
Q

What extensive diagnostic tests are available depending on H&P

A 
EP study
carotid UD
stress test
cardiac imaging
neuro test (MRI/EEG)
Tilt table test
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11
Q

When is a Tilt table test indicated

A

if recurrent episodes of unexplained syncope occur
Tests for vasovagal syncope
Can help patient recognize prodromal symptoms

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12
Q

How do you preform a tilt table test

A

Lie patient down, then tilt patient upright 60-90 degrees

Abn: exaggerated drop in BP w or w/o drop in HR, associated with dizziness and light headed

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13
Q

What if there is a focal deficit on exam/ Normal exam

A

Deficit: CT +/- MRI brain, consider angio

If neuro exam is normal but neuro component suggested, refer for autonomic testing

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14
Q

What is vasovagal syncope

A

common faint, most common cause of syncope
short duration, fatigue
more common in younger patients and females
solitary attacks, no Rx needed

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15
Q

What are triggers for vasovagal syncope

A

heat exposure, prolonged standing, physical exertion

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16
Q

What are classic prodromal symptoms of vasovagal syncope

A

light headed, diaphoresis, palpitations, nausea, visual blurring/tunnel vision, diminution of hearing, pallor

17
Q

What are triggers in situational syncope

A

micturition, cough, defecation, swallowing, emotional state, painful stimuli

18
Q

What is the treatment for vasovagal syncope

A

avoid triggers!
education (counter pressure maneuvers, like tilt training)
If suspected ANS dysfunction, liberalize salt and water intake, compression stockings
May consider pacing

19
Q

What is carotid sinus syndrome

A

syncope associated with carotid sinus stimulation (shaving, tight neck collar, prior head/neck surgery)
Characterized by drop in BP 50+ mmHg, or sinus pause >3 seconds
Usually older patients, VERY rare

20
Q

how can you diagnose CSS

A

carotid massage can reproduce syncope (don’t do if with carotid bruit, prior TIA, stroke, or MI w/in 3 months)

21
Q

How do you treat CSS

A

avoid triggers, consider pacing

22
Q

What do 2017 guidelines recommend for assessing orthostatic hypotension

A

assess 3 minutes after standing

BUT, JAMA 2017 says 1 minute most clinically relevant

23
Q

What are causes of orthostatic syncope

A

Hypovolemia
Meds (CCB, diuretics, vasodilators, BB)
ANS dysfunction (lesions on peripheral nerves AKA MS/parkinsons) (secondary ANS failure d/t DM, alcohol, amyloid)

24
Q

How do you treat orthostatic syncope

A

If d/t dehydration, give fluids
If drug related, stop drug
If neurogenic, compression stocking/ Midodrine, Droxidopa, Fludrocortisone
Physical counter pressure maneuvers
Tilt training
Water intake (peak intake at 30 min)/ liberal salt intake (6-9g/d)

25
Q

What should you do if orthostatic syncope continues to recur

A

consider pharm intervention with Midodrine or Fludrocortisone

26
Q

What is cardiac arrhythmia syncope due to

A 
Afib
SVT
Vtach
high degree AV block
Brugada
27
Q

What does cardiac syncope yield

A

LOWER survival than other syncopes

28
Q

What are bradyarrhythmias due to

A 
Sick Sinus Syndrome (SA node dysfunction causes intermittent pause with tachy-brady syndrome)
AV block (Moritz II, Complete heart block)
29
Q

What are tachyarrhythmias due to

A 
SVT
WPW
Afib/flutter with RVR
V-Tach
V-Fib
Torsades (QT prolonging drugs; anti-emetics like zofran and compazine)
30
Q

What are some QT prolonging drug classes

A 
antiarrhythmics
antimicrobials 
antidepressants 
antipsychotics
Arsenic/Methodone
31
Q

What is obstructive CV syncope due to

A

**Aortic stenosis (think of AS triad; syncope, hypotension, angina!)
Aortic dissection (acute “tearing pain” radiating to back. high mortality)
HCM (small LV, impaired diastolic compliance)
Pulmonary embolism
Cardiac tamponade
(also acute MI, pulm HTN)

32
Q

How do you treat CV syncope

A

Possible pacemaker (ICD)
anti-arrhythmics
fluid (pre-load dependent conditions)

33
Q

What are psychogenic causes of syncope

A

conversion disorder
pseudo-syncope (arm-drop test)
pseudo-seizure

34
Q

How can you differentiate seizure from syncope

A

lateral tongue biting, head/eye turn to one side, hyper salivation suggests epileptic seizure
BUT urinary incontinence can happen with either

35
Q

How can you treat pseudo syncope

A

assess pulse, assist to ground/chair/stretcher, avoid external dangers, attempt to arouse
Long term: treat underlying cause to prevent re-occurrence

36
Q

What does the San Francisco Syncope rule identify

A 
Low-risk its unlikely to benefit from hospital admission. IF they have any of the CHESS criteria, they are higher risk and may need hospitalization
Congestive heart failure Hx
Hematocrit >30%
ECG abnormal (non-SR, new changes)
Shortness of breath
Systolic bp <90
37
Q

What does the Canadian Syncope Arrhythmia risk score identify

A 
small subset of pts that suffer arrhythmia/death w/in 30 days of ED visit for syncope
Criteria include: 
vasovagal predisposition
Hx HD
ED systolic <90 or >180
elevated Trop
QRS duration >130 ms
QT >480 ms
ED dx vasovagal syncope or cardiac syncope
38
Q

How is the Canadian syncope arrhythmia risk score actually scored

A

For 0 points: <1% risk of arrhythmia
For 1-3 points: 1.9-7.5% risk of arrhythmia
For 4-8 points: 14.3-22.2% risk of arrhythmia

Nayla Foundations (18 decks)

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