Syncope

Question 1

what is syncope?

Answer 1

a transient, self limited LOC w/ an inability to maintain postural tone that is followed by spontaneous recover

Question 2

what is pre-sycope?

Answer 2

same sx, but terminates prior to LOC and may include partial loss of postural tone

Question 3

what are some non-cardiac causes of syncope?

Answer 3

vasovagal
autonomic insufficiency
situational
orthostatic

Question 4

what are some cardiac causes of syncope?

Answer 4

-vascular dz
-cardiomyopathy
-valvular dysfxn
CHF
-hypotension
-supraventricular tachycardias
-afib/flutter
bradyarrhythmias
adverse medication response
MI
AD
pulmonary embolus

Question 5

what are exs of SVT causes?

Answer 5

WPW, Brugada, Congenital long QT

Question 6

vasovagal syncope

Answer 6

-susally in standing position, precipitated by fear, emotional stress, pain

Question 7

how does vasovagal syncope present?

Answer 7

Nausea, diaphoresis, fading out, epigastric discomfort, light-headedness precede syncope by minutes

Question 8

what is the mechanism of vasovagal syncope?

Answer 8

efferent vasodepressor reflexes results in decreasedd PVR

Question 9

situational syncope?

Answer 9

known precipitant, reproducible

Question 10

what are causes and the mechanism of situational syncope?

Answer 10

micturition, defecation, deglutition, tussive, carotid sinus syncope
Mechanism: precipitants cause autonomic vasodepression which lead to transient cerebral hypoperfusion

Question 11

orthostatic syncope?

Answer 11

secondary to orthostatic hypotension

Question 12

what causes orthostatic syncope?

Answer 12

Autonomic failure in neurodegnerative diseases such as: Parkinson’s disease, supranuclear palsy, MSA, dementia, spinal cord injury etc.
Other causes: drugs, volume depletion (dehydration)

Question 13

what is the BP definition of orthostatic syncope?

Answer 13

Drop of systolic BP of 20mmHg or Diastolic BP of 10mmHG when going from lying to standing position within 3 minutes. Often with pulse increase of >10-20

Question 14

what are some precipitant factors seen prior to syncope?

Answer 14

Fatigue
Sleep/food deprivation
Warm temperature
ETOH consumption
Pain
Strong emotions (ie fear) 
Positions
Activities:
Exertion
Shaving
Coughing
Voiding
Prolonged standing

Question 15

what are the clinical presentations of syncope?

Answer 15

-rapid onselt LOC that is short in duration with spontaneous complete recover + loss of postural tone

• faintness
• dizziness
• light-headedness
• vertigo
• weakness
• blurred vision
• pallor
• epigastric discomfort
• N
• diaphoresis

Question 16

what are some lab studies included int he workup of syncope?

Answer 16

Orthostatic Vital Signs: PRIOR TO FLUID RESUSCITATION
Glucose level
CMP
CBC 
Cardiac Enzymes
UA
Tox screen if appropriate

Question 17

what are some diagnostic imagint that can be done in the work up of syncope?

Answer 17

• EKG, ECho
• CXR
• Head CT
• Chest/Abdominal inmaging (aortic dissection/PE)
• MRI/MRA

Question 18

when do you try carotid sinus massage?

Answer 18

in pts over 40 with syncope of unkonwnetiology

-diagnostic if syncope reproduced with asystole >3 sec or SBP drop > 50 mmHg

Question 19

cardiac syncope tx

Answer 19

Consider cardiology consult

• Pacer pads if bradyarrythmia suspected
• Stop AV nodal blocking agents
• Eval for pacemaker if > 40 with recurrent syncope with documented asystole. Reduces syncope frequency by > 50%
• Atropine if symptomatic bradycardia and consider pacemaker placement for 2nd degree heart block with symptoms or 3rd degree heart block (asystole)

Question 20

orthostatic syncope tx?

Answer 20

Elevate head of bed
TED stockings
Fludrocortisone
Midodrine
Recommend PO fluid in take

Question 21

what is midodrine

Answer 21

alpha 1-agonist vasodepressor activity