Syncope - Exam 1 Flashcards
What is the difference between syncope and presyncope?
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
What is important to differentiate syncope from?
be able to tell if its dizziness, vertigo or disequilibrium
if it all 3 then most likely not deadly
_______ can also present like a kidney stone
aortic dissection
If it is true syncope, what are the top 4 ddx?
reflex syncope
orthostatic syncope
cardiac arrhythmias
structural cardiopulm disease
What is the difference between narcolepsy and cataplexy? Are each considered syncope?
Narcolepsy (Loss of Consciousness) vs. Cataplexy (Loss of muscle tone)
NOT syncope
In the history, you find that syncope with multiple events with new onset. What should you consider?
consider AV block
In the history, you find that syncope with multiple events over many years. What should you consider?
may be susceptible to vasovagal syncope
In the history, you find that syncope with multiple episodes daily lasting multiple minutes. What should you consider?
psychogenic possibility
What does extended prodrome vs no prodome make you think with regards to the underlying cause? What do you also want to ask?
Extended prodrome - vasovagal
No prodrome - more concerning for cardiac
has this happened before?
What can the patient’s position during syncope tell you about the underlying cause?
Supine
change in position
upright
Supine - more significant for cardiac etiology
Change in position - Orthostatic Hypotension (Can be multiple minutes after change)
Upright - Reflex Syncope (Vasodilation +/- bradycardia)
What are some trigging factors for reflex syncope?
Immediately AFTER exercise
defecation/urination
coughing, swallowing, post-prandial, prolonged standing, fear, sight of blood
True syncope is usually _____ at most as the _____ restores cerebral perfusion
1-2 minutes
supine position
If someone witnessed the syncopal event, what should you ask them?
any seizure movement
were their eyes OPEN or closed?
prodrome symptoms witnessed?
a true seizure are the eyes usually open or closed?
eyes usually open!
syncope with new/severe HA, what should you be thinking?
subarachnoid hemorrhage
DM pts with syncope are at an increased risk for ________. Why?
Orthostatic Hypotension
d/t autonomic neuropathy and hypoglycemia
Syncope, probably want to order EKG. What are you looking for?
looking for QT prolongation greater than 450
lots of drugs cause it!! MANY psych and neuro drugs, antiemetics, antiarrhythmics, antifungals, some antibiotics
QT interval longer than ______ is concern for Torsades
greater than 500
What are 6 concerning features that would point to the syncope cause being cardiac related?
Absence of Prodrome
Event during exertion or supine
Associated with Chest Pain
Family hx of sudden death
Known structural heart disease
Abnormal rhythm hx
What does syncope with low BP make you think?
Sepsis, Cardiac issue, Overdose, Late HF
What does syncope with high BP make you think?
Stroke, early HF, Anxiety
What are some s/s of heart failure?
Bilateral lower extremity swelling
Increased JVD
S3 / S4
What two PE should you do in their entirety?
COMPLETE cardio and complete neuro exam!
if irregular neuro exam -> brain CT
If possible head or neck trauma, what should be your next step in decision making criteria?
Canadian CT rules: if you need a head CT
nexus criteria: if you need xray of cervical spine
Go find the Canadian CT rules and
go find the nexus criteria
What 2 things are required for a pt with syncope that presents to the ER?
EKG and cardiac monitor throughout their stay
Go find the PERC rules
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.
______ should be used if concerned about PE and cannot PERC out
D- Dimer
What is the equation for age adjusted D dimer?
What are the different calculator options for syncope disposition?
Canadian syncope risk score
San Francisco Syncope Rule
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
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
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
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
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
How long is the standard QRS complex? How long is the normal QTc interval?
normal is 80-100
450 is normal
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.
Is a prodome usually present in vasovagal syncope?
YES! prodome is usually present
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
Will cardiac induced syncope have a post episode fatigue?
NOT usually with cardiac causes
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.
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)
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
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)
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
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
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
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!!
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!
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%
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
What is the presentation of subclavian steal syndrome?
Pain, fatigue, coolness, paresthesia, numbness, fatigue, syncope, VERTIGO, DIPLOPIA
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
How do you dx subclavial steal syndrome?
arterial US or CTA with contrast
once admitted will get MRA (angiography)
What is the tx for subclavian steal syndrome?
Statins for generalized atherosclerosis
Antiplatelet / Anticoagulant therapy (ASA/Plavix)
Smoking Cessation
Blood Pressure Management
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
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
What is the presentation of basilar artery insufficiency?
Nausea / Vomiting
Weakness
Numbness
Dysphagia
Dysarthria
Syncope
Vision Changes
How do you dx basilar artery insufficiency?
glucose check/neuro exam
CT brain w/o OR CTA head/neck WITH contrast
HINTS exam
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
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!
What are the 3 components to HINTS exam?
nystagmus
test of vertical skew
head impulse test
What type of nystagmus is worrisome in the HINTS examine?
bidirectional nystagmus
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
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
What is a reassuring HINTS exam?
unidirectional nystagmus
no vertical skew
abnormal head impulse test
need ALL 3 components
What is a worrisome HINTS exam?
ANY of the following:
bidirectional nystagmus
abnormal test of skew
normal head impulse test
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
Are cardiac output and EF typically normal in HCM?
Cardiac out put and ejection fraction are usually normal.
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
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.
What will squatting do the heart murmur associated with HCM?
cause it to DECREASE!!
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
What is the dx study of choice for HCM? What will it show?
Echo
it will demonstrate disproportionate septal hypertrophy.
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
What is the tx for HCM once firmly diagnosed and presents with chest pain?
atenolol 25 to 50 mg orally every day
What is the Wells Criteria? What does it determine?
Determines the pre-test probability of a PE
What do you do next if the pt has a low risk Wells Score and no PERC rules met?
no testing
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
What do you do next if the pt has a intermediate risk Wells score?
D-Dimer
normal: no imaging
elevated D-dimer: imaging
What do you do next if the pt has a high risk Wells score?
straight to imaging
no D-Dimer needed
