Syncope in Adults

Question 1

What is syncope?

Answer 1

Transient, brief, and abrupt loss of consciousness
Absence of postural tone
Complete and rapid recovery
Benign and self-limited

Question 2

Can urinary incontinence happen with syncope?

Answer 2

Yes, especially in older people

Question 3

Can injuries like tongue biting happen with syncope?

Answer 3

Yes, but more common in seizures

Question 4

Is there a post-ictal phase in syncope?

Answer 4

No

Question 5

What are the common causes of syncope?

Answer 5

Vasovagal
Arrhythmia
Neurology/psychiatric disease
Unexplained/idiopathic

Question 6

What are common cardiac causes of cardiac syncope?

Answer 6

Aortic stenosis

Question 7

What is the pathophysiology of vasovagal syncope?

Answer 7

Drop in BP > increase in SV > heart contracts against less-filled left ventricle > mechanoreceptors detect this > send info to tractus solitarius in brainstem > decreases sympathetic drive to heart, and increases vagal tone > vasodilation and bradycardia > decreased cerebral perfusion > syncope

Question 8

What are non-syncope conditions that could be mistake for syncope?

Answer 8

Fall
TIA
- Neurological signs need to be present
Cardiac arrest
Presyncope
- Prodromal symptoms
- Light headedness
- Dizziness

Question 9

What can syncope and headache indicate?

Answer 9

Red flag; eg: subarachnoid haemorrhage

Question 10

What are the symptoms associated with syncope due to a subarachnoid haemorrhage?

Answer 10

Prolonged LOC
Most commonly with seizures
Prolonged recovery

Question 11

What can syncope and chest pain indicate?

Answer 11

Cardiac ischaemia

Arrhythmia

Question 12

What can syncope and dyspnoea indicate?

Answer 12

PE

Question 13

What does the initial evaluation of syncope involve?

Answer 13

Is it syncope or something else
What is the aetiology?
Is there high risk of CV event/death?

Question 14

What is the usual duration of loss of consciousness in syncope?

Answer 14

Brief
Usually around 30 sec
Can be up to couple of min

Question 15

What is the usual duration of loss of consciousness in cardiac syncope?

Answer 15

About 10 sec

Question 16

What is recovery like after syncope?

Answer 16

Complete

Rapid

Question 17

What are associated symptoms that suggest vasovagal syncope?

Answer 17

Nausea
Pallor
Diaphoresis
Hot environment

Question 18

What are associated symptoms that suggest arrhythmia?

Answer 18

Sudden collapse

Question 19

What are associated symptoms that suggest pulmonary embolism?

Answer 19

SOB

Question 20

What are associated symptoms that suggest epilepsy?

Answer 20

Urine/faecal incontinence

Auras

Question 21

What are the precipitating factors of situational syncope?

Answer 21

Cough
Swallowing
Crowded
Standing
Post-prandial
Fear
Pain
Urinating/defaecating

Question 22

What is carotid sinus syncope?

Answer 22

Hyper-sensitive baroreceptors

More common in elderly

Question 23

How is carotid sinus syncope tested?

Answer 23

Carotid sinus massage whilst ECG running

Looking for extreme bradycardia and symptoms

Question 24

What is tilt table testing?

Answer 24

Tilt table, head up to 70 degrees
Tilt for 45 min
Monitor
- HR
- BP
- ECG
Give vasodilator challenge halfway - GTN/isoprenaline
Look for symptoms
Vasodilator syncope >50 mmHg drop with syncope
Cardio-inhibitory syncope >3 sec of asystole/>10 sec of extreme bradycardia (<35 bpm)

Question 25

What is the most common cause of left axis deviation?

Answer 25

Ischaemic heart disease

Question 26

What are the causes of QT prolongation?

Answer 26

Hypomagnesaemia
Hypokalaemia
Hypocalcaemia
Raised intracranial pressure
Altered conscious state
Hereditary
Hypothermia
Drugs

Question 27

What is prolongation of the QT interval associated with?

Answer 27

Increased risk of polymorphic VT = torsades de pointes