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Approach to Syncope

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by

Erma Poulet

on 4 February 2013

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Transcript of Approach to Syncope

History Common presentations to
the emergency department Orthostatic Cardiac
Arrhythmia and main causes Neural reflex Pathophysiology Approach to Syncope I passed out,
fainted, blacked out, lost consciousness for a moment, keel over, fade, went out like a light, collapsed Classification Where to start? How does one systematically
approach each
one of
these patients? Syncope Word originating from late Latin (syncopen) or Greek(synkope)
meaning "to cut up" Why is an approach to
Syncope important? A 15 yr old school girl stands in the camping
ground in Langebaan, chatting to her cousin - suddenly drops to the ground. An 80 yr old grandma's husband hears a cluttering in the kitchen, and finds his wife who has been peeling vegetables on the ground A 46 yr old woman, otherwise well, faints in the supermarket after speaking to her son on the phone. She is brought in by an ambulance Transient global cerebral hypoperfusion -
mostly due to a transient decrease in systemic blood pressure followed by a loss in postural tone Common
Can be dangerous
Can be disabling
Is difficult to find a cause Individual
(patient reasons) Other implications Economic implications -->
Direct: in-hospital expenses
Indirect: lost productivity Structural CV Vasovagal
Carotid sinus
Situational
Cough, sneeze
Post-micturition
Post exercise
Post prandial
GI stimulation
Micturition
Drug induced
Autonomic NS failure
Primary
Secondary
Alcohol induced
Volume depletion
Post exercise
Postprandial Brady
Sick sinus
AV Block
Tachy
VT
SVT
Syndromes
Implanted devices
Drug-induced Aortic Stenosis
Cardiomyopathy
Obstructive CM
Pulmon HPT/PE
Aortic dissection
Pericardial origin
Vascular steal syndromes
Processes to follow History taking
Physical examination
Broad basic investigations
Focused investigations Conclusions Syncope is a symptom and NOT a disease
A flexible, focused approach is required to diagnose the physiologic state that leads to its presentation
Features of the initial Hx and physical exam will guide diagnostic testing Associated symptoms Other important questions: History continued Was the event witnessed?
What happened during the event itself?
Medication use
Background/previous medical history
Psychiatric history Physical exam Broad ED investigations

"routine C15 roll-call" Other Psychogenic pseudosyncope
Cataplexy
Drop attacks ECG "Routine" tests Recommended Cheap, risk free, important clues derived Do only to confirm a clinical suspicion eg electrolyte disturbances
Fingerprick glucose valuable Radiological eg CXR
Preg test in females Syncope Mimics With impairment
or LOC Without LOC Metabolic disorders
Epilepsy
Intoxication
Vertebrobasilar TIA HisTORY Keep in mind: Pt's age
Triggers and associated symptoms
Position or posture
Onset
Type of episode
Syncope during exercise
Comorbidities
Medications Chest pain
Dyspnoea
Palpitations
Prodromes
Sx immediately before or after
Triggers Emotional or physcial stress
Micturition / defecation
Coughing
Swallowing
Prolonged standing in a warm environment
Abn vitals
cardiac auscultation
Lung exam
Vascular exam
Neurologic exam
Injuries
Incontinence
PR
Syncope red flags Structural heart disease
Prev MI
PPM or defibrillator
Abn ECG
Family hx of sudden death
Syncopal related severe injury
Frequent and recurrent episodes (>2 in a year)
Associated palpitations
High risk occupation, possibility of personal or collateral injury Neurally mediated Vasovagal
Carotid sinus
Situational
Cough, sneeze
Post-micturition
Post exercise
Post prandial
GI stimulation
Micturition Orthostatic Drug induced
Autonomic NS failure
Primary
Secondary
Alcohol induced
Volume depletion
Post exercise
Postprandial Brady
Sick sinus
AV Block
Tachy
VT
SVT
Syndromes
Implanted devices
Drug-induced Arrythmic
causes Aortic Stenosis
Cardiomyopathy
Obstructive CM
Pulmon HPT/PE
Aortic dissection
Pericardial origin
Vascular steal syndromes Structural CV causes Carotid sinus massage
Orthostatic challenge
Echo
Cardiac monitoring
Holter
More modalities External Event recorders
Implantable loop recorders
Invasive EP studies
Full transcript