Syncope: Tintinalli Flashcards
So what is syncope & most importantly: how do you pronounce it?
Syncope: symptom complex composed of brief loss of consciousness associated with inability to maintain postural tone that spontaneously & completely resolves without medical intervention. It is different from vertigo, seizures, coma, & altered consciousness.
It is pronounced “SIN-co-pee.” Do not say “sin-cope.” :)
What causes syncope?
Regardless of mechanism, the final pathway is the same: a lack of blood flow or nutrient delivery to both cerebral cortices or the brainstem reticular activating system for 10-15 seconds will lead to loss of consciousness & postural tone.
If you don’t got blood in your brain, you’re gonna fall out.
Why do people wake up when they fall out with syncope?
The reclined posture, the response of the autonomic centers, or a return to a perfusing cardiac rhythm reestablishes perfusion.
What are some disorders that can lead to syncope?
#Vasovagal (reflex mediated): 21% #Cardiac: 10% #Orthostatic: 9% #Medication related: 7% #Seizure: 5% #Neurologic: 4.1% #Unknown: 37%
Why is it important to make a diagnosis for the cause, if possible?
Each diagnostic classification carries prognostic risk. E.g., in the Framingham study, people with heart disease WITH syncope had twice the death rate of those with heart disease WITHOUT syncope.
Which root cause of syncope is the most dangerous?
Cardiac. These are your sudden cardiac death folks.
What’s the 6 month mortality rate for people with documented cardiac syncope?
> 10%
Dang.
What are the 2 categories of cardiac related syncope?
#Structural cardiopulmonary lesions (outflow obstruction, PE, acute MI causing dyskinesia, etc) #Dysrhythmias
Syncope from dysrhythmia is usually gradual: true or false?
FALSE. It is sudden & has no prodromal symptoms.
They just fall over. thump
What is vasovagal syncope?
Reflex-mediated. It’s associated with inappropriate vasodilation, bradycardia, or both as a result of inappropriate vagal or sympathetic tone.
What are the characteristics of vasovagal syncope?
#Sensation of increased warmth #Preceding lightheadedness #Sweating & nausea #Slow, progressive onset of syncope
Carotid sinus hypersensitivity is what type of syncope? What group of patients should be evaluated for this?
It’s a subtype of vasovagal syncope. Should be considered in all older patients with recurrent syncope & negative cardiac evaluations
What is orthostatic syncope? What causes it?
Upon standing, blood is shifted to the lower part of the body & cardiac output drops. Normally the body increases CO to compensate for this, but if autonomic response is not sufficient, decreased cerebral perfusion may occur.
Then they fall over. thump
So if someone presents with orthostatic syncope, we should just tell them it’s benign & to dangle their legs, right?
Nope! Other life-threatening causes of syncope should be ruled out before it is considered benign orthostatic syncope.
What psychiatric illnesses may cause syncope?
#Generalized anxiety disorder #Major depressive disorder #Psychiatric cause is A DIAGNOSIS OF EXCLUSION, assigned only after all organic causes are excluded
Neurologic causes are rarely the cause of syncope: true or false?
True! To be true syncope, the symptom must be transient in nature with a return to baseline. Thus, PATIENTS WITH LOSS OF CONSCIOUSNESS WITH PERSISTENT DEFICITS are not true syncope!
What neurologic issues can cause syncope?
#Brainstem ischemia #Subclavian steal #Vertebrobasiliar atherosclerotic disease #Basilar artery migrains #Subarachnoid hemorrhage (but really they're gonna have more than just syncope with this...)
Medications contribute to syncope. What is the most common type of syncope caused by medications?
Orthostatic!
What drugs are commonly implicated in syncope?
#Antihypertensives #Beta-blockers #Cardiac glycosides #Diuretics #Anti-dysrhythmics #Anti-psychotics #Anti-Parkinsonism drugs #Anti-depressants #Phenothiazines #Nitrates #Alcohol #Cocaine
What population is at increased risk for syncope? What type of syncope?
The elderly are at increased risk for ALL THE SYNCOPE!
What’s the goal of syncope evaluation in the ED?
Identify those at increased risk for immediate decompensation & future risk of morbidity or sudden death.
Who is gonna fall out again right now? Who is gonna fall out & DIE in the future?
What should we look for in a HISTORY for syncope?
#Patient account #Witness accounts #Emphasize events leading up to syncope: position, stimuli, activity, environment, premonitory symptoms #Chest pain or palpitations #Duration of loss of consciousness #Symptoms upon regaining consciousness #Prior history of syncopal event
These symptoms should be very concerning when accompanying syncope:
#Chest pain (acute MI, aortic dissection, PE, aortic stenosis) #Palpitations (rhythm disturbances) #Shortness of breath (PE) #Headache (subarachnoid hemorrhage) #Abdominal or back pain (abdominal aortic aneurysm, ectopic pregnancy)
Syncope with no warning or associated with exertion should make you think:
#Cardiac dysrhythmia #Structural cardiopulmonary lesion
