Emergency lectures - Syncope
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  • Differential diagnosis includes lid-threatening illnesses, Difficult to diagnose in the ED and difficult to predict who will have another possibly life-threatening event.
  • Very long list of causes, some benign and others life-threatening, I will not discuss all of these in detail Our job is to diagnose syncope, determine a cause and treat and if unable to find a cause determine the risk for another event
  • First try to categorize the cause
  • Mechanical impairment usually with exertion
  • Large class of restrictive cardiomyopathies, dilated cardiomyopathies
  • Self-limited, reversible, harmless
  • Antihypertensives-alpha and beta blockers, diuretics
  • I am not going to describe the workup for each disease process but high light important points
  • Risk stratification for syncope is similar to risk stratification for chest pain

Emergency lectures - Syncope Presentation Transcript

  • 1. Syncope ____________________________
    • Hugh Hemsley MD FACEP
    • Department of Emergency Medicine
    • Riverside Regional Medical Center
    • Virginia, USA
    • February 2011
  • 2. Goals of lecture ____________________________
    • Definition of syncope
    • Pathophysiology
    • Causes
    • Patient evaluation
    • Patient disposition
  • 3. Syncope: definition ____________________________
    • A brief loss of consciousness with the inability to maintain postural tone followed by a spontaneous and complete recovery without medical intervention
  • 4. Epidemiology _________________________
    • 1-2% of all Emergency Department visits
    • 6% of hospital admissions
    • Affects all age groups
    • Increasing incidence with age
    • Increasing morbidity and mortality with age
  • 5. Pathophysiology _________________________
    • Brain needs a constant supply of oxygen and nutrients
    • Symptoms start after 5-10 seconds of cerebral perfusion disruption
    • Syncope is caused by the lack of adequate blood flow to the brain
    • Sudden decrease in cerebral perfusion: no symptoms prior to the syncopal event
    • Gradual decrease in cerebral perfusion: symptoms will develop prior to the syncopal event
      • Weak, lightheaded, dizzy, blurred vision, warmth, diaphoresis
  • 6. Pathophysiology ___________________________
    • Rapid restoration of consciousness after cerebral perfusion has been restored
      • Dysrhymia has resolved
      • Patient becomes supine
      • Blood supply to the brainstem is restored following a TIA
  • 7.
    • Same pathophysiology as syncope
    • Cerebral perfusion is restored and symptoms resolve before the loss of consciousness
    • Same risks and Emergency Department evaluation as syncope
    Near-Syncope ____________________________
  • 8. Causes of Syncope ____________________________
    • Ventricular tachycardia
    • Ventricular fibrillation
    • Supraventricular tachycardia
    • Asystole
    • Heart block
    • Sinus bradycardia
    • Sick sinus syndrome
    • Carotid sinus sensitivity
    • Prolonged QT Syndrome
    • Valvular heart disease
    • Pulmonary hypertension
    • Pulmonary embolism
    • Hypertrophic cardiomyopathy
    • Restrictive cardiomyopathy
    • Cardiac myxoma
    • Pacemaker or Prosthetic valve malfunction
    • Myocardial infarction
    • Aortic dissection
    • Aortic Stenosis
    • Congenital heart disease
    • Pericardial tamponade
    • Hypovolemia
    • Hemorrhage
    • Dehydration
    • Vasovagal
    • Vasomotor insufficiency
    • Orthostatic hypotension
    • Cough
    • Urination
    • Defecation
    • Swallow
    • Neuralgia
    • Subclavian steal
    • Medications
    • Transient ischemic attack
    • Migraine headache
    • Subarachnoid hemorrhage
    • Psychiatric
    • Breath holding (pediatrics)
    • Hypoglycemia
    • Valsalva maneuver
  • 9. Causes of syncope ___________________________
    • Cardiac
    • Vasovagal or Neurally-mediated or Reflex-mediated
    • Orthostatic hypotension
    • Cerebrovascular
    • Psychiatric
    • Medications
  • 10. Cardiac syncope ____________________________
    • Cardiac syncope has the highest morbidity and mortality
    • Can be the initial presentation of undiagnosed cardiovascular disease
    • Near-syncope Syncope Sudden death
    • Identify those patients at a risk for another syncopal event
  • 11. Cardiac syncope ___________________________
    • Inability to maintain an adequate cardiac output
      • Cardiac output = stroke volume + heart rate
      • Structural heart disease
        • Mechanical impairment to venous return and cardiac outflow
        • Usually related to physical exertion and the inability to increase cardiac output
      • Dysrhythmias
        • Can affect stroke volume, heart rate or both
  • 12. Structural heart disease ____________________________
    • Valvular heart disease
      • Aortic Stenosis-most common obstructive cardiac lesion in the elderly
        • exertional chest pain, dyspnea, syncope
      • Mitral, pulmonic, tricuspid stenosis
      • Prosthetic valve malfunction or thrombus
    • Cardiomyopathy
      • Hypertrophic cardiomyopathy
        • Assymetric hypertrophy of the right or left ventricle
        • Number one cause of death in competitive athletes
        • Second most common cause of sudden death in adolescents.
  • 13.  
  • 14. Causes of Syncope _________________________
    • Pulmonary embolism
    • Pulmonary hypertension
    • Pericardial tamponade
      • Traumatic
      • Medical
    • Congenital heart disease
    • Myxoma
    • Myocardial ischemia/infarction
    • Aortic dissection
      • Can present with transient pain
  • 15. Dysrhythmias ___________________________
    • Tachydysrhythmias
      • V. Tachycardia, V. Fibrillation, Supraventricular Tachycardia
    • Bradydysrhythmias
      • Asystole, Sinus bradycardia, heart block, sick sinus syndrome
    • Conduction system disease
      • Pre-excitation syndromes
        • Wolf-Parkinson-White syndrome
      • Long-QT syndrome
      • Brugada syndrome
      • Obtain a family history of sudden death
    • Pacemaker malfunction
  • 16. Wolf-Parkinson-White
  • 17. Brugada Syndrome
  • 18. Dysrhythmias ____________________________
    • Can present with sudden loss of consciousness or preceding symptoms < 5 seconds
    • Consider when a patient has syncope at rest
    • Syncope depends upon:
      • Degree of underlying heart disease
      • Ability of the nervous system to compensate for the decrease in cardiac output
  • 19. Ventricular tachycardia
  • 20. Vasovagal syncope ____________________________
    • Also referred to as reflex-mediated or neurally-mediated syncope
    • Most common cause of syncope
    • Good prognosis
    • Inappropriate vagal tone causing bradycardia and vasodilation
    • Slow progression of symptoms
      • Nausea, diaphoresis, weak, dizzy, lightheaded, blurred vision, warmth
    • Less common in the elderly population due to an impaired autonomic nervous system
      • Consider life-threatening etiologies first
  • 21. Vasovagal syncope ___________________________
    • Etiologies-fainting
      • Prolonged standing
      • Fear, fatigue, emotional distress, pain, unpleasant sight, smell, or sound
      • Cough
      • Urination
      • Defecation
      • Swallowing
  • 22. Vasovagal syncope ____________________________
    • Carotid sinus sensitivity
      • Carotid Body-stretch sensitive structures located at the carotid bifurcation
      • Stimulation causes bradycardia and hypotension
      • More common in males, elderly, history of heart disease
      • Can be stimulated by shaving, turning the head, or tight fitting collar.
  • 23. Carotid Body
  • 24. Orthostatic hypotension ___________________________
    • Venous pooling occurs in the lower extremities when a person stands
      • Normal compensatory response-increase in heart rate and peripheral vascular resistance causing an increase in cardiac output and blood pressure.
      • If the normal autonomic response is inhibited then blood pressure continues to drop, cerebral perfusion decreases and syncope occurs if the patient remains upright.
      • Symptoms usually occur with 3 minutes of standing.
  • 25. Orthostatic hypotension ____________________________
    • Causes of impaired autonomic response
      • Volume loss
        • Dehydration
        • Bleeding-ectopic pregnancy, leaking aneurysm
        • Medications- diuretics
      • Heart disease and poor vascular tone
        • Elderly
        • Medications
  • 26. Medications ___________________________
    • Antihypertensives
    • Antidysrhythmics
    • Antipsychotic
    • Antiparkinsonism drugs
    • Antidepressants
    • Nitrates
    • Alcohol
  • 27. Cerebrovascular ____________________________
    • Uncommon cause of syncope
      • Persistent neurologic symptoms following loss of consciousness: stroke-not syncope
      • Transient ischemic attack (TIA)
        • Vertebrobasilar circulation disease causing transient brainstem ischemia
        • Subclavian Steal Syndrome-exercise of the arm shunts blood away from the vertebrobasilar system to the subclavian artery causing transient ischemia
      • Migraine headache
      • Subarachnoid hemorrhage
        • Bleeding causes increased intracranial pressure, decreased cerebral perfusion pressure and syncope
  • 28. Subclavian steal syndrome
  • 29. Syncope versus Seizure ______________________________
  • 30. Psychiatric _____________________________
    • Common with anxiety and depression
    • Younger population
    • Multiple preceding symptoms
      • Crying, shouting, increased motor activity
    • Etiology-hyperventilation
    • Make the diagnosis of psychiatric syncope only after all other causes have been ruled out
  • 31. Pediatric syncope ____________________________
    • Usually orthostatic hypotension, vasovagal, or breath holding
    • Rarely cardiac
      • Congenital heart disease
      • dysrhythmia
  • 32. Breath holding syncope ____________________________
    • Unusual after age 6 years
    • Majority occur between 6 and 18 months
    • Crying starts following an emotional trigger
      • Pain, fear, anger
    • Breath holding occurs during end expiration causing the patient to become pale or cyanotic
    • Decreased cerebral perfusion causes loss of consciousness
      • Syncopal episode is brief
      • Seizure-like activity may occur
      • Spontaneous resolution, no intervention needed
  • 33. Evaluation of syncope _____________________________
    • Goal of ED evaluation is to identify those patients with immediate life-threatening conditions and those with a future risk of serious morbidity or sudden death
    • Thorough history and physician exam will determine the cause of syncope in the majority of patients in whom an etiology can be determined
  • 34. History
    • History
      • Events and symptoms prior to, during, and after the syncopal event
        • Chest pain, abdominal or back pain, shortness of breath, palpitations, headache, focal neurologic deficit suggest a serious etiology
        • Single car motor vehicle accident, driver passed out and wrecked the car
        • Historical information could be limited due to patient amnesia, no eyewitnesses, or conflicting eyewitness reports
        • Syncope versus seizure
  • 35. Evaluation of syncope ___________________________
    • Past medical history
      • History of cardiovascular or neurologic disease-CHF
      • Risk factors for atherosclerotic vascular disease
      • Previous syncopal event, is the etiology known?
    • Medications-include non-prescription drugs
    • Family history of sudden death or “fainting”
  • 36. Evaluation of syncope ____________________________
    • Physical exam
      • Vitals signs-resting pulse and blood pressure
      • Blood pressures in both arms
      • Orthostatic vital signs
        • Supine 5 minutes, measure the pulse and blood pressure 1 and 3 minutes after standing
        • A decrease in blood pressure of 20mm Hg with symptoms or a decrease in systolic pressure less than 90mm Hg is considered positive.
          • Interpret results with caution in high risk patients. Up to 40% of patients older than 70 and 23% of patients younger than 60 will have a positive orthostatic test, a 20mm Hg decreased in pressure, look also for symptoms
  • 37. Evaluation of syncope ___________________________
    • Physical exam
      • Cardiac-murmurs or bruits
      • Neurologic exam- new deficits
      • Trauma without defensive injuries to the hands or legs
      • Rectal exam-check for gastrointestinal bleeding
    • Laboratory testing, CT scans, MRI
      • Low yield
      • Testing should be directed by findings obtained during the history and physical exam.
      • Pregnancy test in reproductive females
  • 38. Evaluation of syncope ____________________________
    • EKG and cardiac monitoring
      • Low yield <5%
      • Still obtain as part of the routine workup because life-threatening disorders can be diagnosed
        • Acute ischemia
        • Evidence of prior cardiovascular disease
        • New EKG changes
        • Rhythm or conduction abnormalities
        • Brugada Syndrome
  • 39. Disposition ____________________________
    • Cause of syncope has been determined
      • Cardiac or cerebrovascular syncope should be admitted for further testing and treatment.
      • Vasovagal, orthostatic, and psychiatric syncope can be discharged if causative condition has been treated in the ED. This group of patients are not at an increased risk of cardiovascular morbidity or mortality
  • 40. Disposition ___________________________
    • Cause of syncope cannot be determined
      • A cause for the syncopal event can not be determined in up to 4o% of patient following a thorough evaluation.
      • Risk stratification.
        • Identify those patients at risk for another event and admit for monitoring and further evaluation
  • 41. Risk stratification ___________________________
    • Martin et al. Annals of EM 1997
      • Risk factors for dysrhythmia or death at one year
        • Abnormal EKG
        • History of dysrhythmia
        • Age greater than 45
        • History of CHF
        • No risk factors 4.4%-7.7% occurrence
        • 3 or 4 risk factors 57%-80% occurrence
  • 42. Risk stratification ____________________________
    • Sarasin, et. al. Annals of EM 2003
      • Risk factors for dysrhythmic syncope at one year in a group of patients experiencing syncope of unknown etiology
        • Abnormal EKG
        • History of CHF
        • Age greater than 65
        • O% no risk factors
        • 6% one risk factor
        • 41% two risk factors
        • 60% three risk factors
  • 43. Risk stratification ______________________________
    • Colivicchi et. al. European Heart Journal 2003
      • OESIL score to predict one year mortality
        • Age greater than 65
        • History of cardiovascular disease
        • Syncope without preceding symptoms
        • Abnormal EKG
        • Score O- O% 12 month mortality
        • Score 1- .8% 12 month mortality
        • Score 2- 19% 12 month mortality
        • Score 3- 35% 12 month mortality
        • Score 4- 57% 12 month mortality
  • 44. Risk stratification ___________________________
    • Quinn et al, Annals of Emergency Medicine, 2004
      • San Francisco Syncope Rule-predicting another cardiac event in 7 days
        • History of CHF
        • Hematocrit < 30
        • Abnormal EKG
        • Shortness of breath
        • Triage systolic BP < 90
  • 45. Risk stratification ____________________________
    • Risk factors associated with increased mortality
      • History of CAD
      • History of CHF
      • Elderly
      • Abnormal cardiovascular exam
      • Sudden onset
      • Occurs during exertion
      • Abnormal EKG
  • 46.
    • Thank you
    • Questions?