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1. SYNCOPE
INDIAN DENTAL ACADEMY
Leader in continuing dental education
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2. This is a story of a patient who
fainted in a dental chair…
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3. What is SYNCOPE..
•Definition
•Predisposing factors
•Pathophysiology and clinical manifestations.
•Management
•Drugs used in management
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4. Definition
 Greek word `SYNKOPTEIN` - to cut or break
 Syncope is defined as transient loss of
consciousness due to reduced cerebral blood flow.
 A transient, self limited loss of consciousness usually
leading to falling. The onset of syncope is relatively
rapid, and the subsequent recovery is spontaneous,
complete, and relatively prompt.
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5. Types of Syncope
 Vaso-Vagal syncope
 Cardiogenic syncope
 Postural syncope
 Carotid Sinus syncope
 Reflex syncope
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6. Causes
 Cardiogenic syncope
Insuffficient pumping action of heart
- Arrythmia
- Structural cardiac disease
e.g. valvular disease,
obstructive cadiomyopathy
 Postural syncope
- Drugs e.g. antidepressants, beta blockers
- Fluid depletion, prolonged standing
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7.  Insufficient vascular tone
-Autonomic failure
- Primary e.g. multiple system atrophy
- Secondary e.g. diabetic & other neuropathy
- Drugs e.g. antidepressants, beta blockers
 Insufficient circulatory volume
- Hypovolemia e.g. Addisons disease, hemorrhage,
diuretics
 Reflex Syncope
- Inappropriate neural control:
- cough, micturition, sneezing: reflex vagal stimulation
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8. Predisposing Factors
 Psychogenic factors
Fright
Anxiety
Emotional stress
Pain esp. unexpected &sudden
Sight of blood or surgical instrument
 Non-psychogenic factors
Erect sitting or standing posture
Hunger or missed meal
Poor physical condition
Hot, humid, crowded environment
Exhaustion
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9. PATHOPHYSIOLOGY &
CLINICAL MANIFESTATIONS
ENGLE classified mechanisms producing syncope into 4 categories:

Inadequate delivery of blood / O2 to brain
∴ ↓ed cerebral metabolism.

General / local metabolic deficiencies
∴ ↓ed cerebral metabolism

Direct /Reflex effects on that part of CNS that
regulates consciousness and equilibrium.

Psychic mechanisms affecting levels of
consciousness with their respective mechanisms of
actions.
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10. PATHOPHYSIOLOGY & CLINICAL MANIFESTATIONS OF
VASODEPRESSOR SYNCOPE:
Grouped into 3 different phases:
Pre-Syncope
Syncope
Post-Syncope
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11. Pre-Syncope Phase
STRESS
Emotionally triggered ex: fear
Sensorially triggered
ex: unexpected pain
Release of CATECHOLAMINES in blood
(Epinephrine and Norepinephrine)
‘FIGHT-OR-FLIGHT’ response
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12. ‘FIGHT-OR-FLIGHT’ response
↓ in peripheral vascular resistance.
↑ in blood flow to skeletal muscles.
MUSCULAR ACTIVITY OCCURS
Blood from muscles pumped back to heart
MUSCULAR ACTIVITY DOES NOT OCCUR
Pooling of blood in muscles
No peripheral pooling of blood
Decreased blood return to heart
BP remains at / alone baseline level
Signs and symptoms of
vasodepressor syncope
do not develop
Decrease in circulating blood volume
Drop in arterial BP
Decrease in cerebral blood flow.
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13. Compensatory Mechanisms
 Baroreceptor reflex
Carotid sinus
Hering N
Aortic Arch
Aortic N
IX N
XN
NTS
VMC
Spinal Centre
Blood Vessel
Nucleus Ambiguus
XN
Heart
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14. What to Look For??
Early:
1.Feeling of warmth.
2.Loss of color, pale/ ashen-gray
skin.
3.Heavy perspiration.
4.complaints of feeling bad/faint.
5.Nausea
Late:
1.
Pupillary dilatation.
2.
Yawning.
3.
Hyperpnoea
4.
Visual disturbances.
5.
Dizziness.
6.
Loss of consciousness
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15. SYNCOPE PHASE…
(Did you know??)

CRITICAL LEVEL of cerebral blood flow for the maintenance of
consciousness.
30ml of blood / 100gm of brain tissue/ min.

NORMAL VALUE of blood flow is 50-55 ml/100gm/min.
- Equivalent to 70mm Hg SBP in normotensive patients.
- Reached with SBP>70mm Hg in patients with atherosclerosis
and high BP.

Human brain uses- 20% of total body O2
- 6.5% of total glucose consumed by body.

For a normal individual in supine position - Cerebral blood flow –
750ml/min.
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16. Clinical Features:
 Breathing -Irregular, jerky and gasping.
 Dilation of pupils.
 Cerebral ischemia -




Convulsive movements.
Muscular twitching of hands, legs or facial
muscles.
Bradycardia
↓ BP
Pulse-weak and thready.
Loss of consciousness + Generalized muscular
relaxation.
↓
Partial / complete airway obstruction
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17. For recovery
↓
Remove factor that precipitated episode.
Place victim in supine position with legs elevated
slightly.
↓
Improvement in venous return to heart
Increase in blood flow to brain.
↓
Cerebral blood flow exceeds critical level necessary for
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consciousness.
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18. MANAGEMENT OF
VASOVAGAL SYNCOPE
 As soon as signs and symptoms are noted-
Terminate all procedures
↓
Place patient in supine position with legs slightly elevated and back
of dental chair at 10° i.e. TRENDELENBURG POSITION
↓
muscular movement aids in return of blood from periphery.
↓
O2 if necessary (monitor vital signs)
↓
Aromatic ammonia vapours crushed and held under patients nose.
↓
Speeds recovery by direct stimulation of respiratory center
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Note –if no response-- BASIC LIFE SUPPORT
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19. Pregnant woman in supine position
↓
Gravid uterus presses on inferior vena cava.
↓
∴CAVAL COMPRESSION / SUPINE HYPOTENSION
SYNDROME
↓
Acute fall in cardiac output
↓
Recovery delayed
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20. Clinical Features





Pallor, nausea, weakness and sweating.
Disorientation and confusion.
Increase in arterial BP
Heart rate – returns to baseline level.
Pulse becomes stronger.
Tendency for patient to faint again may persist for many hrs if
patient assumes a sitting position or stands too soon.
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21. DEFINITITIVE CARE
Administration of O2.
Monitoring of vital signs – BP, HR, Respiratory rate.
Performing additional procedures:




Loosening of tight clothes such as ties, collars.
Ammonia vapours – stimulates both breathing
and muscular movements.
Cold towel over patient’s forehead.
Blanket if patient is shivering.
If bradycardia persists – Atropine (i.v./i.m.)

Reassure patient.




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22. POST-SYNCOPE STAGE
 Determine precipitating factors and prevent
recurrence of syncope.
 No dental treatment for next 24 hours.
 Arrange for patient to be escorted home.
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23. DRUGS USED IN MANAGEMENT OF VASOVAGAL SYNCOPE
 Atropine
given if bradycardia persists
competitively inhibits acetyl-choline
Dose - 0.5 mg i.v./i.m./ s.c.
 Dextrose – Restores blood glucose levels.
Dose – 1-2 ampules of 5% dextrose i.v.
 Midoprine HCl – Vasopressor
α1-agonist
↓
acts on receptor of arteriolar and venous vasculature
↓
∴↑ in vascular tone
↑ in BP
Dose – 10mg tid
 Beta blockers – propranolol, atenolol
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24. ….. and then, the doctor and the patient lived
happily ever after.
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