Approach to Syncope


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Simplified and systematic approach to a case of syncope

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Approach to Syncope

  1. 1. APPROACH TO SYNCOPE Prepared by Dr.Mostafa Meshaal Supervised by Dr.Amir Masoud Sabah Medical Hospital
  2. 2. Case • A 27-year-old man attended the outpatient clinic due • to a history of recurrent episodes of syncope and presyncope • since the age of 7. All of the episodes had been • triggered by seeing blood or by being given an injection. • The patient had a normal physical examination • His ECG was recorded
  3. 3. ECG
  4. 4. • A 17 year old female collapsed while playing football. • Her mother says that she has always been fit and well the only thing that she had an ear infection 2 days previously for which had been started on erythromycin. • She didn’t have any jerky movement during the collapse • Her clinical examination was unremarkable
  5. 5. ECG
  6. 6. SYNCOPE • Definition • Mechanism • Causes • How to approach • Algorithm for managing cases in ED • Risk stratification • Summary
  7. 7. Definition • Syncope is a transient loss of consciousness, associated with loss of postural tone, with spontaneous return to baseline neurologic function requiring no resuscitative efforts.
  8. 8. Mechanism • Global hypoperfusion of both the cerebral cortices or focal hypoperfusion of the reticular activating system.
  9. 9. Is it common? • Accounts for one to three percent of all ED visits and hospital admissions in the United States. • One-third of individuals are likely to have a syncopal episode during their lifetime. • The incidence of syncope increased with age, with a sharp rise at age 70 years due to age- and disease- related abnormalities that impair the ability to respond to physiologic stresses that would ordinarily not cause syncope • cardiac syncope have a high incidence of subsequent cardiac arrest (approximately 24 percent)
  11. 11. Cardiac syncope •Cardiac arrhythmias •Structural cardiac or cardiopulmonary disease •Ischemia
  12. 12. Cardiac syncope •Cardiac arrhythmias
  14. 14. 3rd degree heart block
  15. 15. SVT
  16. 16. Mobtiz type II block
  17. 17. Brugada syndrome
  18. 18. Sinus pause
  19. 19. Cardiac syncope •Cardiac arrhythmias Hemodynamic instability •Ventricular tachycardia •Paroxysmal supraventricular tachycardia •Long QT syndrome •Brugada syndrome •Bradycardia: Mobitz type II or 3rd degree heart block •Significant sinus pause >3 seconds & SA node dysfunction •Implanted device (pacemaker, ICD) malfunction •Drug-induced proarrhythmias
  20. 20. Cardiac syncope • Structural cardiac or cardiopulmonary disease: Blood flow obstruction Abrupt episodic drops in cardiac output • Cardiac valvular disease “AS, MS, PS” • Obstructive cardiomyopathy • Atrial myxoma • Acute aortic dissection • Pericardial disease/tamponade • Pulmonary embolus/pulmonary hypertension • Acute myocardial infarction/ischemia
  21. 21. NON Cardiac • Neurocardiogenic syncope “vasovagal or vasodepressor syncope” • "Classical vasovagal syncope" refers to syncope triggered by emotional or orthostatic stress such as venipuncture (experienced or witnessed), painful or noxious stimuli, fear of bodily injury, prolonged standing, heat exposure, or exertion. • Situational syncope • Carotid sinus syncope • Glossopharyngeal neuralgia
  22. 22. NON Cardiac • Orthostatic hypotension • Autonomic failure • - Primary autonomic failure syndromes (eg, pure autonomic failure, multiple system atrophy, Parkinson's disease with autonomic failure) • - Secondary autonomic failure syndromes (eg, diabetic neuropathy, amyloid neuropathy) • - Post-exercise • - Post-prandial • Drugs (and alcohol)-induced orthostatic syncope • Volume depletion • - Hemorrhage, diarrhea, Addison's disease
  23. 23. NON Cardiac • Neurovascular syncope: • Vascular steal syndromes
  24. 24. CAUSES OF NON-SYNCOPAL ATTACKS • Episodes that may be confused with syncope include disorders without impairment of consciousness and disorders with partial or complete loss of consciousness . • Seizures — They can mimic syncope. • Metabolic or toxic abnormalities —. Hypoglycemia and encephalitis can cause coma, stupor, and confusion, but rarely syncope. Nevertheless, if a patient does not recall the history surrounding the event or if the event was unwitnessed, distinguishing coma from syncope can be difficult.
  25. 25. CAUSES OF NON-SYNCOPAL ATTACKS • Neurologic Syncope : • subarachnoid hemorrhage • transient ischemic attack • complex migraine headache. • Psychiatric syncope • Drug induced loss of consciousness — Drugs of abuse and alcohol may cause a transient loss of consciousness, but generally these patients manifest signs of toxicity, and do not spontaneously return to normal neurologic function immediately after regaining consciousness. Alcohol can also cause symptomatic orthostasis by impairing vasoconstriction.
  26. 26. •You see what you know
  28. 28. HISTORY • What actually had happened? • From the patient: • What did he feel just before the collapse? • Was there loss of consciousness? • How long did it take for him to feel back to normal? • From a witness: • Color of the patient during the episode • Seizure activity • Duration of the episode • Speed of recovery
  29. 29. HISTORY • Age: Young patients more often experience neurocardiogenic syncope. Emergency clinician must consider the possibility of dysrhythmia particularly if other concerning factors exist (eg, exertional syncope, family history of sudden death). • Associated symptoms and triggers • chest pain, Dyspnea • Palpitations • Headache • Nausea and vomiting, diaphoresis, and pallor • Position
  30. 30. HISTORY • Exertional syncope? • Seizure versus syncope? • Factors suggestive of seizure include : • - Prodrome (aura) different from that described for vasodepressor syncope • - Episode of abrupt onset associated with injury • - Presence of a tonic phase before the onset of rhythmic clonic activity • - Head deviation or unusual posturing during the episode • - Tongue biting (particularly involving the lateral aspect of the tongue) • - Loss of bladder or bowel control • - Prolonged postevent (postictal) phase during which the patient is confused.
  31. 31. HISTORY • Medications • Previous episodes • Family history • Associated injury
  32. 32. PHYSICAL EXAM • Vital signs • Irregular pulse • Low patient oxygen saturation • Orthostatic vital signs • Discrepancies between upper extremities in pulse or blood pressure • General examination • Intraoral exam • Neck exam: Carotid bruit, murmurs, JVP • Injury assessment
  33. 33. PHYSICAL EXAM • Cardiac examination: • S3 or S4 • Murmurs • Lung examination • Neurologic examination: • Any focal abnormality?
  34. 34. INVESTIGATIONS • Electrocardiogram : (ECG) • factors thought to be suggestive of arrhythmia- induced syncope: • Prolonged intervals (QRS, QTc). • Severe bradycardia. • Preexcitation. • Evidence of myocardial infarction. • Low voltage in the standard limb leads, suggesting pericardial effusion. • Abnormal conduction syndromes (eg, Wolf-Parkinson-White and Brugada).
  35. 35. INVESTIGATIONS • Holter monitoring • Echocardiography • Neurological: • CT brain & MRI • EEG • Laboratory evaluation : • FBC & hematocrit • RBS • Electrolytes • Pregnancy test
  36. 36. Tilt table test
  37. 37. Algorithm for Syncope in ED
  38. 38. Risk stratification
  39. 39. Factors that lead to stratification as high risk for adverse outcome • Abnormal ECG: acute ischemia, dysrhythmias, or significant conduction abnormalities. • History of cardiac disease, especially presence of heart failure • Persistently low blood pressure (systolic <90 mmHg) • Shortness of breath with event or during evaluation • Hematocrit <30 (if obtained) • Older age and associated comorbidities • Family history of sudden cardiac death
  40. 40. Summary • Syncope is a common presentation in the emergency setting • Diagnosing cardiac syncope is especially important because the one-year mortality of such patients approaches 30 percent, significantly higher than noncardiac syncope or syncope of unknown etiology • Obtain an ECG in all syncope patients. • Don’t miss life threatening causes • hemorrhage (eg, gastrointestinal, subarachnoid), pulmonary embolism, and cardiac syncope from arrhythmia or acute coronary syndrome. • If you can’t reach obvious cause do risk stratification
  41. 41. References • ECG for Emergency Physician • Ammal Mattu and william Bradly 2003 • Approach to the adult patient with syncope in the emergency department - Uptodate • Daniel McDermott , James Quinn • Syncope Cases • Roberto Garcia-Civera, 2006
  42. 42. Thank you