Syncope Flashcards
Definition
Rapid onset of loss of consciousness.
- Self-limiting: recovers within seconds/ minutes.
- Due to lack go global perfusion.
Classifications of syncope according to causes
SNAP
S(structural)
N(Neurally mediated)
A(Arrhythmias)
P(Postural/ Orthostatic)
Structural causes of syncope
Cardiac
- Valvular disease
- Coronary heart disease/ Acute coronary syndrome
- Cardiomyopathy
- Tamponade
- Congestive heart failure/ Pulmonary oedema
Aortic dissection
Pulmonary embolism
Drug induced
Pacemaker malfunction
Neurally mediated causes of syncope
Vasovagal
Carotid sinus syndrome
- pressure on Carotid sinus= triggers vasodilation via baroreceptor.
Situational
- Post-micturition/ defecation
- Coughing, sneezing
- Post exercuse
- Swallowing
- Sneezing
Arrhythmia causes of syncope
AV heart blocks:
- Type 2, 3
- Bundle branch block
Wolff-Parkinson-White syndrome
Inherited: Long QT, Brugada’s
Bradycardias/ Tachycardias
- SAN dysfunction
Postural causes of syncope
Primary autonomic failure syndromes
Secondary autonomic failure
Volume depletion
Primary autonomic failure syndrome that cause syncope
Multi-system atropy
- Parkinson’s
- Lewy body dementia
- Cerebellar degeneration
Pure autonomic failure
- Degeneration of autonomic system
Secondary autonomic failure that causes syncope
Diabetes
CNS disease
Drug-induced
- beta blockers
- Anti-hypertensives
- Vasodilators
History of syncope
- Before faint
General
- Fatigue?
- Hot environment
- Alcohol consumption
- Emotional distress
Any warning symptoms
- Pain
- Dizziness: vertigo, lightheadedness
- Aura/ hallucinations
- Ringing in ears
- Nausea, vomitting, haematemesis, Melena
- Chest pain, palpitations, SOB
- Visual disturbance/ double vision
- Weakness, sensory disturbance
What was happening before syncope:
- Situational: exercise, micturition, defecation, cough, sneeze etc.
- Were they sitting/ standing/ change positions
- Previous trauma
History of syncope
- During faint
Was consciousness actually loss?
Was anything hit during fall?
What height did they fall from?
Was there any tongue biting or tonic clonic convulsions?
Incontinence?
History of syncope
- During faint
Any new symptoms:
- New onset of confusion/ decreased cognition
- Pain: chest, MSK, head
- Nausea/ vomitting
- Visual disturbance
- Speech or language changes
How long did it take to recover?
- Post-ictal fatigue?
- How long did the loss of consciousness last for?
PMH
Neurological
- Previous stroke
- Epilepsy
Cardiovascular
- Orthostatic hypotension
- Congential heart disease
- Valvular disease
- Hypertrophic heart disease
- Pulmonary arterial hypertension
Arrhythmias
- Brugada’s syndrome (abnormal channel mutation)
- Heart block
- Long QT syndrome (repolarisation problem)
FH
History of any inherited cardiac arrhythmias
Family history of sudden cardiac death
FH of exertion syncope
FH of premature cardiac disease
DH
Antihypertensives
- Diuretics
- Vasodilators
Beta-blockers
Antidepressants
Negative chronotropes
Sedatives: haloperidol, Benzes, antiepileptics
Hypoglycaemic agents
- Insulin
- Sulphonyureas
Examination neuro
CN exam
- Weakness, visual disturbance can indicate stroke
- Can reveal
Upper limb
- Weakness
- Tone
- Co-ordination: can indicated POCI, cerebellar disease or vestibular disease
Lower limb
- Same as upper limb
Gait
- Ataxic gait
- Shuffling gait?
Investigations for syncope
Bloods
- Anaemia
- Toxicity
- Hypercoaguable or haemophilic disease
ECG
- Rule out cardiac cause
Tilt table test
- Orthostatic hypotension
CT head
- If weakness or cognitive decline is present
Echocardiogram
- If murmur/ valvular disease is suspected
EEG
- If epilepsy/ seizure is suspected
Urine
- Toxicology screen
Blood tests for syncope
FBC
- Anaemia
- Infection
LFT
- Toxicity
- Clotting
U+Es
- Electrolyte imbalance
- Dehyradation
Glucose
- Hypoglycaemia
Seizure screen: CK,
Morning cortisol/ SynACTHen test
- When Addision’s is suspected
Treatment of syncope (general)
Treat and manage underlying cause when identified
- Arrhythmias: pacemaker, lifestyle modifications
Treat symptoms/ signs that can propagate syncope
- Increasing BP= give fluids, vasopressors, lifestyle changes, physical manoeuvres
- Increasing HR= Atropine,
- Correcting anaemia
- P
Anticoagulation if clot is suspected
- Heparin/ warfarin
- Supportive care
Treatment of arrhythmia causes of syncope
Treat the underlying cause of arrhythmia
Pacemaker
Lifestyle modification
Treatment of neural mediated causes of syncope
Patient education
- Avoiding triggering factors (such as, if situational)
- Reducing susceptibility
Physical manoeuvres to keep BP up
- Squatting
- Arm tensing
- Leg crossing
Volume expansion
- Salts can be contraindicated in hypertensive disease
Pharmacological
- Fludrocortisone
- Midodrine
