Syncope in Adults

Question 1

Define syncope

Answer 1

Abrupt TLOC
Absence of postural tone
Complete and rapid recovery
Benign and self-limited

Question 2

What % of syncopal episodes are complicated by injury?

Answer 2

30%

Question 3

When is there a risk of sudden death in a syncopal episode?

Answer 3

When the underlying cause is an arrhythmia

Question 4

List 4 common causes of syncope

Answer 4

Vasovagal (most common; neurally mediated)
Arrythmia
Unexplained/idiopathic
Neurology or psychiatric disease (less common)

Question 5

List 7 non-syncope conditions which may be mistaken for syncope

Answer 5

Fall (mechanical)
TIA
Cardiac arrest (these require CPR, pharmacological agents or DC reversion)
Pre-syncope with prodromal symptoms, light-headedness and dizziness
Metabolic derangements (e.g. hypoglycaemia, hyperglycaemia)
Acute intoxication (e.g. EtOH)
Hypoxia

Question 6

Syncope + headache: what should you consider?

Answer 6

Serious causes of headache e.g. SAH

Question 7

Syncope + chest pain: what should you consider?

Answer 7

Cardiac ischaemia

Arrhythmia

Question 8

Syncope + dyspnoea: what should you consider?

Answer 8

PE

Question 9

What factors are important to ascertain in the initial evaluation of a possible syncopal episode?

Answer 9

Is it really a syncopal episode or another type of event? (E.g. seizure)
Has the aetiology been determined?
Is there evidence suggestive of a high risk CV event or death?

Question 10

List 6 aspects of Hx important to ascertain in an episode of syncope

Answer 10

Onset (usually sudden)
Duration of LOC
Recovery (slower suggests post-ictal, not syncope)
Loss of postural tone
PHx of recurrent episodes
Association with injury

Question 11

List 6 possible differentiating symptoms which may indicate the underlying cause of a patient’s LOC

Answer 11

Nausea, pallor, diaphoresis, hot environment: vasovagal
Sudden collapse: arrhythmia
SOB: PE
Angina symptoms: ischaemia, arrhythmia
Abnormal neurology: central cause
Urine or faecal incontinence, aura: epilepsy

Question 12

List some precipitating factors for situational syncope

Answer 12

Cough
Swallowing
Crowded environment
Standing
Post-prandial
Fear
Pain
Urination/defecation

Question 13

What signs might be observed in a patient experiencing LOC due to vagal surge?

Answer 13

Bradycardia

Hypotension

Question 14

What might be the cause of syncope associated with neck movement?

Answer 14

Hypersensitive carotid sinus

Question 15

List 4 possible causes of exertional syncope

Answer 15

AS
HOCM
Ventricular arrhythmia
Prolonged QT

Question 16

Miss M, 18 year old student
Collapsed after standing in a hot crowded area, waiting at the tennis centre
Felt light-headed, nauseated then collapsed
Hx: sudden LOC, spontaneous recovery, no witnessed seizure activity or urinary incontinence, no confusin post-episode, similar episode 6/12 ago
What is the most likely diagnosis? What are some other differentials?
What might you expect to find on examination?
What Ix should be ordered?

Answer 16

Vasovagal syncope
DDx: arrhythmia, PE
O/E: may be pallor, signs of dehydration, bradycardia, hypotension with otherwise normal CV, abdominal, respiratory, neurological examination
Ix: FBE, UEC, ECG, and consider orthostatic challenge, carotid sinus massage, tilt table testing, echocardiogram, holter monitoring

Question 17

List 8 basic Ix which may be appropriate for an uncomplicated episode of syncope

Answer 17

FBE
UEC
ECG
Orthostatic challenge
Carotid sinus massage
Tilt table testing
Echocardiogram
Holter monitoring

Question 18

What is the demographic most commonly affected by neurocardiogenic vasovagal syncope?

Answer 18

Young, healthy patients

Question 19

If a patient has suffered 2 or more syncopal episodes, how likely are they to suffer further recurrent syncope?

Answer 19

54%

Question 20

22 year old man, university student
Drank plenty of alcohol on Saturday night
Woke to his mobile phone on a Sunday morning
Jumped out of bed, 30 secs later his housemate heard him hit the floor
Recovers quickly with no injury, rehydrates and sees GP 6/24 later
Referred to ED for check-up
Likely diagnosis?
Ix?

Answer 20

DDx: vasovagal, cardiac
Ix: ECG

Question 21

62 year old male truck driver, working 2 jobs (18/24 per day)
Drove 8 hours non-stop
Walked in to house, went to make a cup of tea and felt dizzy, had syncopal episode
Heard his wife on phone to ambulance as he was regaining consciousness
No heart murmur or failure
PHx: similar episode previously with Ix echo and stress test normal
Ix?

Answer 21

ECG (showed prolonged QT), consider 8 hour troponin and monitoring

Question 22

List 5 causes of prolonged QT syndrome

Answer 22

Hereditary: Lange Nielsen (QT prolongation, deafness), Romano Ward
Altered conscious state, raised ICP
Hypothermia
Metabolic: hypomagnesiuaemia, hypokalaemia, hypocalcaemia
Drugs: Na+ channel blockers (type 1a), TCA

Question 23

What is the risk with prolonged QT syndrome?

Answer 23

Increased risk of polymorphic VT and death

Question 24

23 year old young woman
Presents following her third syncopal episode in two years
Each time she has seen GP or ED with no cause found
Each episode sudden onset with no warning
O/E: NAD

Answer 24

ECG showed WPW

Question 25

What is the relationship between age and amnesia of syncopal event?

Answer 25

Younger less likely to experience amnesia (10-40% experience amnesia in an escalating incidence according to age)

Question 26

Syncope red flags

Answer 26

Exertional syncope
Supine syncope
PHx: IHD
FHx: sudden early death
Ix: abnormal ECG, structural heart disease

Question 27

Mr M, 50 year old mechanic
Collapse after complaints of severe central chest pain
Acutely SOB and profuse sweating
Smoker (10 cigarettes/day)
PHx: mild HTN, no DM
FHx: no FHx of IHD
O/E: pale, sweating and unwell, BP 100/60, HR 84 sinus rhythm, RR 20, SaO2 97%, normal CV examination and no evidence of pulmonary congestion
List 6 relevant Ix
DDx?

Answer 27

Ix: basic bloods, CXR, serial ECGs, cardiac enzymes, echocardiogram, consider coronary angiogram
DDx: AMI, arrhythmia, PE

Question 28

Mrs S, 72 year old pensioner
Collapse with brief of LOC, tachypnoea and some R sided pleuritic chest pain
O/E: RR 24, T 37.6, HR 110, SaO2 93% on RA, chest clear with normal percussion and breath sounds
Ix: CXR normal, ABG pH 7.5/CO2 30 mmHg/pO2 62 mmHg on RA, CTPA performed
Likely diagnosis?

Answer 28

PE (CTPA shows clot)

Question 29

Mrs H, 50 year old accountant
Complains of severe headache and then collapses with a brief LOC
Other symptoms include N+V, mild R facial droop and R arm weakness
PHx: recurrent headache (taking paracetamol PRN), no previous collapse, no HTN/DM/hypercholesterolaemia
FHx: father died of CVA at 80
Smoker (5 cigarettes/day), social drinker
O/E: BP 150/90, HR 90 regular, RR 20, no neck stiffness, no carotid bruits, mild R arm weakness with power 5-/5, mild hypertonia and hyperreflexia in R arm and R leg, mild R facial droop and slurred speech
DDx?
Ix?
What cerebral territory are her symptoms consistent with?

Answer 29

CVA
Intracranial haemorrhage
Intracerebral aneurysm with small bleed
Migraine with cerebral spasm
Ix: CT brain (looking for acute haemorrhage, intracranial lesion, subdural haemorrhage), MRI brain (looking for acute changes in left temporo-parietal lesion)

Question 30

When will an acute thrombotic stroke become apparent on non-contrast CT?

Answer 30

5 days after event

Question 31

Mrs H, 85 year old pensioner, lives in special accommodation
Recurrent falls, usually when standing up suddenly or while walking to the dining room
Found on floor by staff, ?LOC
PHx: orthopnoea, PND, peripheral oedema, palpitations, previous AMI with PPM, HTN, DM, mild dementia, PD
Ex-smoker
Rx: warfarin, anti-Parkinsonian medications, anti-HTN, diuretics
O/E: frail lady with multiple bruises including a periorbital haematoma, mildly confused, BP 140/80 lying 120/70 standing, HR 92 AF, fluid overload (elevation of JVP, bilateral pulmonary congestion, SOA), dyspnoea on minimal exertion, walks with single point stick, shuffling gait, Parkinsonism
Ix?

Answer 31

Ix: FBE, UEC, TFT, cardiac enzymes, CK, CXR, ECG, 24 hour holter, pacemaker r/v, CTB

Question 32

Mrs H, 85 year old pensioner, lives in special accommodation
Recurrent falls, usually when standing up suddenly or while walking to the dining room
Found on floor by staff, ?LOC
PHx: orthopnoea, PND, peripheral oedema, palpitations, previous AMI with PPM, HTN, DM, mild dementia, PD
Ex-smoker
Rx: warfarin, anti-Parkinsonian medications, anti-HTN, diuretics
O/E: frail lady with multiple bruises including a periorbital haematoma, mildly confused, BP 140/80 lying 120/70 standing, HR 92 AF, fluid overload (elevation of JVP, bilateral pulmonary congestion, SOA), dyspnoea on minimal exertion, walks with single point stick, shuffling gait, Parkinsonism
CXR findings: PPM, enlarged heart, bilateral pleural effusions, prominent upper lobe vessels, alveolar opacity in bases
Dx?
In light of this, list 6 possible causes of her collapse
Mx?

Answer 32

CCF (with rapid AF)
Possible causes: HF, arrhythmia, postural hypotension (secondary to medications, autonomic neuropathy), ataxia (neuromuscular disorder or weakness), PD, anaemia
Mx: acute treatment of HF and rapid AF with correction of electrolyte imbalance/anaemia (also consider stopping warfarin), long term treatment involves a multi-disciplinary approach with physio, OT, dietitian and social worker