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    Syncope Syncope Presentation Transcript

    • Syncope Anthony Ho, DO PGY4 Emergency Medicine
    • Introduction
      • Symptom complex composed of brief loss of consciousness associated with inability to maintain postural tone that spontaneously resolves without medical intervention
      • Epidemiology
        • 2% of ER visits
        • 1 out of 4 persons will have in lifetime
        • Elderly have the highest risk of morbidity
        • Near syncope is the same process
        • Differentiate from vertigo or dizziness
    • “ Passed Out”
    • Pathophysiology
      • Lack of blood flow to brainstem reticular activating system for 10-15 seconds
      • Reduction of cerebral perfusion by 35% for 5-10 seconds
      • Most common inciting event is drop in cardiac output
      • Least common is vasospasms or other alterations in flow to CNS
    • Etiology
      • Causes of syncope
        • Cardiac
          • Structural cardiopulmonary disease
            • Valvular heart disease, aortic stenosis, tricuspid stenosis, cardiomyopathy, pulmonary HTN, Congenital Heart disease, Myxoma, pericardial disease, aortic dissection, PE, MI, ACS.
          • Dysrhythmias
            • Bradydysrhythmias, Stokes-Adams attack, Sinus node disease, 2 nd -3 rd degree blocks, pacemaker malfunction, tachydysrhythmias, Vtach, torsades de pointes, SVT, A Fib or Aflutter.
        • Neural/Reflex mediated
          • Vasovagal
          • Situational
            • Cough, micturition, defecation, swallow, neuralgia,
          • Carotid Sinus Syndrome
        • Orthostatic
        • Psychiatric
        • Neurologic
          • TIA, Subclavian Steal, Migraine
        • Medications
    • Cardiac Syncope
      • 6 month mortality >10%
      • Underlying Structural Cardiopulmonary disease
        • Think Aortic Stenosis in Elderly
        • Think Hypertrophic Cardiomyopathy in Young
        • PE can lead to Pulmonary outflow obstruction
        • AMI or ischemia can lead to decrease CO
      • Dysrhythmias
        • Both tachy- and bradysrhythmias can lead to transient hypoperfusion
        • Syncope is SUDDEN ONSET without prodromal symptoms
    • Vasovagal or Neurally/Reflex-Mediated Syncope
      • Syncope associated to inappropriate vasodilation, bradycardia, or both in response to inappropriate vagal or sympathetic tone
      • SLOW PROGRESSIVE ONSET with associated prodrome
      • Carotid Sinus Hypersensitivity, consider in elderly patients with recurrent syncope and negative cardiac evaluations
    • Orthostatic Syncope
      • Occurs within 3 minutes of standing
      • Orthostatic tests positive if decrease in SBP by >20mmHg or drop in pressure to <90
      • Non specific test: 40% of asymptomatic patients >70 are positive
      • Many life threatening causes of syncope have orthostatic symptoms, do not attribute as benign just because you have positive orthostatics
    • Psychiatric Illnesses
      • Diagnosis of exclusion
      • Associated with generalized anxiety and major depressive disorders
      • i.e. Hyperventilation syndrome  hypocarbia  cerebral vasoconstriction
    • Neurologic Syncope
      • Loss of consciousness with persistent neurologic deficits or AMS are not true syncope
      • Stroke Syndromes with syncope
        • Brainstem ischemia
        • Posterior circulation ischemia (diplopia, vertigo, nausea)
        • Subclavian steal syndrome
      • Seizures often mimic syncope
    • Medication-Induced Syncope
      • Usually contributes to orthostatic syncope
      • Antihypertensive mediations (BB, CCB), diuretics, and proarrythmics
    • Elderly Population
      • Cardiovascular risk is the best predictor of mortality with syncope
      • Highest risk group
        • Calcified blood vessels are less compliant
        • LV becomes less compliant, increasing dependence on atrial kick
      • Incidence of vasovagal syncope decreases with age
      • Increased orthostatic syncope
    • Evaluation
      • ED goal
        • 1. Avoid litigation!
        • 2. Admit patients that will benefit (receive a diagnosis) from admission.
        • 3. Discharge patients that won ’t die (or have complications) before their follow-up.
        • 4. Diagnose in the ED reversible or deadly causes
        • Careful history
        • Thorough Physical Exam
        • EKG interpretation
    • History
      • Symptoms of cardiopulmonary or neurological origin
        • Chest pain, palpitations, shortness of breath, headache, abdomen or back pain, focal deficits.
      • Family history of dysrhythmias, sudden cardiac death, prolonged QT
    • Physical Exam
      • Focus on cardiovascular and neurological systems
        • Murmurs, rales (think HCM, AS)
        • Focal neurological exam
        • Rectal examination
    • EKG
      • Cardiopulmonary disease
        • Acute ischemia
        • dysrhythmia (WPW, Brugada)
        • Heart block
        • Prolonged QT
    • Other test
      • Carotid massage
        • Only small number of patients with hypersensitivity with have true Carotid Sinus Syndrome
      • Hyperventilation maneuver
      • Neurologic Testing
        • CT/MRI not warranted for isolated syncope
    • Unexplained Syncope
      • Unknown etiology in 40% of patients
      • If diagnosis made, 80% of the time is in the emergency room!
    • Disposition
      • SF Syncope Rules
        • CHF
        • Hematocrit <30
        • EKG changes
        • SBP<90
        • SOB
      • Boston Syncope Criteria
        • 25 criteria
    • Practice Guideline
    • Post ED Evaluation
      • Cardiac Syncope
        • Electrocardiographic monitoring
        • Echocardiography
        • Electrophysiology testing
        • Stress testing
      • Neurologic Syncope
        • CT/MRA/Carotid Doppler
        • EEG
      • Reflex-mediated syncope
        • Tilt-table testing
      • Psychogenic
        • Psychiatric testing