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Emergency Med > Syncope - Exam 1 > Flashcards

Syncope - Exam 1 Flashcards

1
Q

What is the difference between syncope and presyncope?

A

syncope: transient loss of postural tone and consciousness due to lack of blood flow to the brain. Rarely last more than 1 minute. Return to baseline without resuscitation and NO postical state

vs

presyncope: symptoms of fainting without losing consciousness

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2
Q

What is important to differentiate syncope from?

A

be able to tell if its dizziness, vertigo or disequilibrium

if it all 3 then most likely not deadly

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3
Q

_______ can also present like a kidney stone

A

aortic dissection

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4
Q

If it is true syncope, what are the top 4 ddx?

A

reflex syncope

orthostatic syncope

cardiac arrhythmias

structural cardiopulm disease

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5
Q

What is the difference between narcolepsy and cataplexy? Are each considered syncope?

A

Narcolepsy (Loss of Consciousness) vs. Cataplexy (Loss of muscle tone)

NOT syncope

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6
Q

In the history, you find that syncope with multiple events with new onset. What should you consider?

A

consider AV block

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7
Q

In the history, you find that syncope with multiple events over many years. What should you consider?

A

may be susceptible to vasovagal syncope

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8
Q

In the history, you find that syncope with multiple episodes daily lasting multiple minutes. What should you consider?

A

psychogenic possibility

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9
Q

What does extended prodrome vs no prodome make you think with regards to the underlying cause? What do you also want to ask?

A

Extended prodrome - vasovagal

No prodrome - more concerning for cardiac

has this happened before?

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10
Q

What can the patient’s position during syncope tell you about the underlying cause?
Supine
change in position
upright

A

Supine - more significant for cardiac etiology

Change in position - Orthostatic Hypotension (Can be multiple minutes after change)

Upright - Reflex Syncope (Vasodilation +/- bradycardia)

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11
Q

What are some trigging factors for reflex syncope?

A

Immediately AFTER exercise

defecation/urination

coughing, swallowing, post-prandial, prolonged standing, fear, sight of blood

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12
Q

True syncope is usually _____ at most as the _____ restores cerebral perfusion

A

1-2 minutes

supine position

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13
Q

If someone witnessed the syncopal event, what should you ask them?

A

any seizure movement

were their eyes OPEN or closed?

prodrome symptoms witnessed?

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14
Q

a true seizure are the eyes usually open or closed?

A

eyes usually open!

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15
Q

syncope with new/severe HA, what should you be thinking?

A

subarachnoid hemorrhage

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16
Q

DM pts with syncope are at an increased risk for ________. Why?

A

Orthostatic Hypotension

d/t autonomic neuropathy and hypoglycemia

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17
Q

Syncope, probably want to order EKG. What are you looking for?

A

looking for QT prolongation greater than 450

lots of drugs cause it!! MANY psych and neuro drugs, antiemetics, antiarrhythmics, antifungals, some antibiotics

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18
Q

QT interval longer than ______ is concern for Torsades

A

greater than 500

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19
Q

What are 6 concerning features that would point to the syncope cause being cardiac related?

A

Absence of Prodrome

Event during exertion or supine

Associated with Chest Pain

Family hx of sudden death

Known structural heart disease

Abnormal rhythm hx

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20
Q

What does syncope with low BP make you think?

A

Sepsis, Cardiac issue, Overdose, Late HF

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21
Q

What does syncope with high BP make you think?

A

Stroke, early HF, Anxiety

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22
Q

What are some s/s of heart failure?

A

Bilateral lower extremity swelling
Increased JVD
S3 / S4

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23
Q

What two PE should you do in their entirety?

A

COMPLETE cardio and complete neuro exam!

if irregular neuro exam -> brain CT

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24
Q

If possible head or neck trauma, what should be your next step in decision making criteria?

A

Canadian CT rules: if you need a head CT

nexus criteria: if you need xray of cervical spine

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25
Go find the Canadian CT rules and
26
go find the nexus criteria
27
What 2 things are required for a pt with syncope that presents to the ER?
EKG and cardiac monitor throughout their stay
28
Go find the PERC rules
29
When are PERC rules used?
The PERC rule can be applied to patients where the diagnosis of PE is being considered, but the patient is deemed low-risk. A patient deemed low-risk by physician’s gestalt who is also <50 years of age, with a pulse <100 bpm, SaO2 ≥95%, no hemoptysis, no estrogen use, no history of surgery/trauma within 4 weeks, no prior PE/DVT and no present signs of DVT can be safely ruled out and does not require further workup.
30
______ should be used if concerned about PE and cannot PERC out
D- Dimer
31
What is the equation for age adjusted D dimer?
32
What are the different calculator options for syncope disposition?
Canadian syncope risk score San Francisco Syncope Rule
33
What are the 6 pt parameters that disqualify a pt from using Canadian Syncope calculator?
Major trauma / head trauma causing LOC Intoxication - ETOH or drugs Language barrier LOC >5 min Change in mental status Obvious witnessed seizure
34
What is the criteria for San Francisco Syncope Rule? If yes to any of the questions, then what?
If yes to any of the 5 predictors then at high risk for a serious outcomes any are positive, need to admit for observation
35
If a pt has a canadian syncope risk score of -3 to 0, what should you do next?
low risk: -3 to 0, patient requires 2 hours ED observation
36
If a pt has a canadian syncope risk score of 1 to 3, what should you do next?
1-3 is medium risk: 6 hours of ED observation and consider external cardiac monitoring for 15 days
37
If a pt has a canadian syncope risk score of 4 to 11, what should you do next?
high/very high risk is 4 - 11: 6 hours of ED observation is required and consider admission. If discharged, need external cardiac monitoring for 15 days
38
How long is the standard QRS complex? How long is the normal QTc interval?
normal is 80-100 450 is normal
39
What are the 3 different types of reflex syncope? Which one is MC? What is the underlying cause?
**vasovagal** MC situational carotid sinus syncope All reflex syncopes refer to vasodilation and/or bradycardia causing systemic hypotension and cerebral underperfusion. The most basic understanding describes increased parasympathetic tone and decreased sympathetic nerve control resulting in the bradycardia and vasodilation.
40
Is a prodome usually present in vasovagal syncope?
YES! prodome is usually present
41
What is the classic presentation of vasovagal syncope? Will the HR increase or decrease?
donating/seeing blood, being emotionally upset, AFTER vigorous exercise occurs in a sitting or standing position may have post episode fatigue HR will decrease in reflex syncope
42
Will cardiac induced syncope have a post episode fatigue?
NOT usually with cardiac causes
43
What will the PE and EKG show of a it with vasovagal syncope? What should you do next?
everything will be negative/normal dx of exclusion If convinced vasovagal, patient is evaluated with a risk evaluation device. Low risk and many moderate risk will be discharged home with appropriate follow-up with primary care. High risk will be admitted.
44
What is orthostatic hypotension defined as?
Defined as ↓ 20 mm/Hg systolic or 10 mm/Hg diastolic often HR ↑ 20 BPM (decrease in reflex syncope)
45
How should you dx orthostatic hypotension? Why does it occur?
Supine and standing BP and pulse will be obtained. Patient should rest comfortably for 5 minutes before first reading. BP should be retaken after patient is standing for 2 minutes. neuro and arterial walls lose elasticity and become calcified and a sluggish response to vasoconstriction causes BP to drop for a brief time after position change
46
What are some drug classes that can cause orthostatic hypotension?
diuretics adrenergic antagonists ( -zosin, -olol) alpha-2-adrenergic agonists (-idine) vasodilators (NTG, hydralazine, -afil) ACE/ARBs : RAS inhibitors CCB (Verapamil, Diltiazem) dopamine antagonists (chlorpromazine, atypical antipsychotics) antidepressants (trazodone, amitripyline, SSRIs) SGLT2 inhibitors (-flozin)
47
How will carotid sinus syncope present? What is a very common pt?
A reflex syncope (drop in HR) d/t turning of head, tight collar, shaving older male with have atherosclerotic vascular or anyone who may have acquired neck structural abnormalities due to sx in that area
48
How do you dx carotid sinus syncope? What is the ED tx? Disposition?
using the history and carotid massage carotid massage positive: if ↓ systolic BP >50mmHg or symptomatic ED tx: NONE!! follow up with PCP -> consider pacer or Midodrine
49
How do you perform carotid sinus massage?
palpate trachae and find the carotid artery just lateral to it. two fingers and rub the carotid artery in a circle between 5 and 10 times
50
How will aortic stenosis present? What dx test should you order?
Chest pain, syncope, dyspnea with systolic murmur radiating to the carotids heard loudest at the aortic post narrowed pulse pressure echo!!
51
What should you NOT give a pt with aortic stenosis in the ED? What is the disposition?
do NOT give BB or NON-DHP (verapamil, diltiazem) likely admit to floor and call cardio!
52
What are the indications for an aortic valve replacement?
Severe AS in symptomatic pt Severe AS undergoing CABG, aortic, or valve surgery Severe AS with LV dysfunction, EF < 50%
53
What is subclavian steal syndrome caused by? Will the BP be higher or lower in the effected arm?
stenosis of the subclavian artery, proximal to the origin of the vertebral vessel, results in decreased perfusion pressure to the distal subclavian artery, leading to retrograde flow in the ipsilateral vertebral artery with exercise of the ipsilateral arm. aka when you go to move your arm and you have a blockage in the subclavian artery, the blood flows backward out of the brain causing the syncope BP will be LOWER in the effected arm
54
What is the presentation of subclavian steal syndrome?
Pain, fatigue, coolness, paresthesia, numbness, fatigue, syncope, VERTIGO, DIPLOPIA
55
In subclavian steal syndrome, where is the arm stealing blood from? _____ may also be heard in the supraclavicular area
Loss of blood from the POSTERIOR circulation of the brain falling into the right extremity bruit
56
How do you dx subclavial steal syndrome?
arterial US or CTA with contrast once admitted will get MRA (angiography)
57
What is the tx for subclavian steal syndrome?
Statins for generalized atherosclerosis Antiplatelet / Anticoagulant therapy (ASA/Plavix) Smoking Cessation Blood Pressure Management
58
What is the disposition for subclavian steal syndrome?
Admit with consult to Vascular Surgery all symptomatic patients Discharge with quick vascular surgery outpatient if incidental finding
59
What is basilar artery insufficiency? What makes symptoms worse?
Basilar artery carries blood to the brainstem (core functions including heart rate, blood pressure, and respiration regulation), cerebellum (balance and coordination), and occipital lobes of the brain (vision) Change of head position may cause symptoms
60
What is the presentation of basilar artery insufficiency?
Nausea / Vomiting Weakness Numbness Dysphagia Dysarthria Syncope Vision Changes
61
How do you dx basilar artery insufficiency?
glucose check/neuro exam CT brain w/o OR CTA head/neck WITH contrast HINTS exam
62
What is the HINTS exam? When is it used?
Distinguishes between central causes of vertigo from peripheral. Vestibular neuritis vs stroke use if vertigo lasts hours to days
63
What is the tx for basilar artery insufficiency? What is the disposition?
call neuro and vascular sx!! Possible endarterectomy, cholesterol management, Antiplatelets, Smoking cessation admit everyone!
64
What are the 3 components to HINTS exam?
nystagmus test of vertical skew head impulse test
65
What type of nystagmus is worrisome in the HINTS examine?
bidirectional nystagmus
66
What is a worrisome finding in the vertical skew test portion of the HINTS exam?
when uncovering one eye the eye moves medially and either up or down
67
What is the head impulse testing looking for? What is a normal finding?
checking to see if their is a nerve problem abnormal finding is GOOD (better to have a nerve problem than a brain problem) tell the pt to remain eyes fixed on your nose and then briskly turn the head 20 degrees off midline and then back to midline. Normal pt eyes should remain focused on your nose the throughout the movement. Abnormal it will take a second for the pt's eye to refocus on your normal or nystagmus will be present
68
What is a reassuring HINTS exam?
unidirectional nystagmus no vertical skew abnormal head impulse test need ALL 3 components
69
What is a worrisome HINTS exam?
ANY of the following: bidirectional nystagmus abnormal test of skew normal head impulse test
70
What is hypertrophic cardiomyopathy characterized by? What happens next?
asymmetric left ven­tricular and/or right ventricular hypertrophy primarily involving the intra­ ventricular septum The result is decreased compliance of the left ventricle leading to impaired diastolic relaxation and diastolic filling
71
Are cardiac output and EF typically normal in HCM?
Cardiac out­ put and ejection fraction are usually normal.
72
what is the trend with regards to symptoms severity in HCM? What is the MC symptom?
tend to be more severe as patients get older DOE then -> chest pain, palpitations and syncope
73
What does the PE reveal in a pt with HCM?
reveals a fourth heart sound and a systolic ejection murmur heard best at the lower left sternal boarder or apex that does NOT typically radiate to the neck.
74
What will squatting do the heart murmur associated with HCM?
cause it to DECREASE!!
75
What will the EKG reveal in HCM? CXR?
The ECG in hypertrophic cardiomyopathy is nonspecific, but often demon­strates left ventricular hypertrophy and left atrial enlargement. Deep S waves may be seen with large septal Q waves (>0.3 mV) and upright T waves. CXR is usually normal
76
What is the dx study of choice for HCM? What will it show?
Echo it will demonstrate disproportionate septal hypertrophy.
77
What is the tx for syncope and HCM in the ED?
Patients with suspected hypertrophic cardiomyopathy who have syncope should be hospitalized for cardiac monitoring and a thorough evaluation due to risk of sudden cardiac death tx is primarily supportive
78
What is the tx for HCM once firmly diagnosed and presents with chest pain?
atenolol 25 to 50 mg orally every day
79
What is the Wells Criteria? What does it determine?
Determines the pre-test probability of a PE
80
What do you do next if the pt has a low risk Wells Score and no PERC rules met?
no testing
81
What do you do next if the pt has a low risk Wells Score and 1 positive PERC rule?
D-Dimer normal: no imaging elevated D-dimer: imaging
82
What do you do next if the pt has a intermediate risk Wells score?
D-Dimer normal: no imaging elevated D-dimer: imaging
83
What do you do next if the pt has a high risk Wells score?
straight to imaging no D-Dimer needed
84

Emergency Med (21 decks)

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