Practical approach to giddiness

1. APPROACH TO SYNCOPE

2. SYNCOPE
• ABRUPT, TRANSIENT, COMPLETE LOSS OF CONSIOUSNESS
ASSOCIATED WITH
• INABILITY TO MAINTAIN POSTURAL TONE
• WITH RAPID AND SPONTANEOUS RECOVERY
• OCCURS DUE TO CEREBRAL HYPOPERFUSION

3. HISTORY
• 1. DID THE PATIENT EXPERIENCE COMPLETE LOC?
• 2. WAS THE LOC TRANSIENT WITH A RAPID ONSET AND SHORT
DURATION?
• 3. DID THE PATIENT RECOVER SPONTANEOUSLY, COMPLETELY, AND
WITHOUT SEQUELAE?
• 4. DID THE PATIENT LOSE POSTURAL TONE?
• IF THE ANSWER TO ONE OR MORE OF THESE QUESTIONS IS
NEGATIVE, OTHER NON SYNCOPAL CAUSES OF TRANSIENT LOC
SHOULD BE SUSPECTED

4. HISTORY ABOUT THE SYNCOPAL ATTACK
• QUESTIONS ABOUT CIRCUMSTANCES JUST PRIOR TO THE ATTACK
• POSITION (SUPINE, SITTING or STANDING)
• ACTIVITY (REST, CHANGE IN POSTURE, DURING OR AFTER
EXERCISE, DURING OR IMMEDIATELY AFER URINATION,
DEFECATION, COUGH OR SWALLOWING)
• PRECIPITATING EVENTS (INTENSE PAIN, FEAR, NECK MOVEMENTS)
• PROLONGED STANDING

5. QUESTIONS ABOUT THE ATTACK
• PRIOR TO ATTACK:
• NAUSEA/ VOMITING, ABDOMINAL DISCOMFORT, FEELING OF COLD,
SWEATING, AURA, PAIN IN NECK OR SHOULDERS, BLURRED VISION
• PALPITATION
• END OF THE ATTACK:
• CONFUSION, INJURY, MUSCLE ACHES, SKIN COLOR, CHEST PAIN,
PALPITATION, URINARY OR FECAL INCONTINENCE

6. ABOUT THE ATTACK :(EYEWITNESS)
• WAY OF FALLING
• SKIN COLOR (PALLOR, CYANOSIS, FLUSHING)
• DUARTION OF LOC
• BREATHING PATTERN
• MOVEMNTS (TONIC, CLONIC, TONIC-CLONIC, AUTOMATISM,
MYOCLONIC JERKS)
• DURATION OF MOVEMENTS
• TONGUE BITING

7. BACKGROUND HISTORY
• H/O CARDIAC DISEASE OR METABOLIC DISEASE (DIABETES)
• FAMILY H/O CARDIAC DISEASE , SYNCOPE, OR SUDDEN DEATH
• NEUROLOGICAL HISTORY (PARKINSONISM, EPILEPSY, NARCOLEPSY)
• H/O DRUG INTAKE (ANTI HYPERTENSIVE, ANTI ANGINAL, ANTI
ARRYTHMIC, DIURETICS, QT PROLONGING DRUGS) & H/O ALCOHOL
INTAKE
• IDENTIFYING THE PRECIPITATING FACTORS INCLUDING BODY POSITION
AND ACTIVITY IMMEDIATELY BEFORE SYNCOPE
• DETAILED DESCRIPTION OF THE SYNCOPAL EPISODE

8. CLASSIFICATION OF SYNCOPE
• REFLEX (NEURALLY MEDIATED SYNCOPE)
• VASOVAGAL SYNCOPE
• SITUATIONAL SYNCOPE
• CAROTID SINUS SYNCOPE
• SYNCOPE DUE TO ORTHOSTATIC HYPOTENSION
• PRIMARY OR SECONDARY AUTONOMIC FAILURE, DRUG INDUCED OH,
VOLUME DEPLETION
• CARDIOVASCULAR SYNCOPE
• ARRHYTMOGENIC SYNCOPE
• SYNCOPE DUE TO STRUCTURAL HEART DISEASE

10. NEURALLY MEDIATED SYNCOPE
• ABSENCE OF HEART DISEASE
• LONG HISTORY OF RECURRENT SYNCOPE
• NAUSEA / VOMITTING ASSOCIATED WITH SYNCOPE
• AFTER SUDDEN UNEXPECTED UNPLEASANT SIGHT, SMELL, SOUND OR PAIN
• DURING A MEAL OR POST PRANDIAL
• WITH HEAD ROTATION OR PRESSURE ON CAROTID SINUS (AS IN SHAVING,
TUMORS, TIGHT COLLARS)
• AFTER EXERTION

11. SYNCOPE DUE TO ORTHOSTATIC HYPOTENSION (OH)
• AFTER STANDING UP
• PROLONGED STANDING ESPCIALLY IN CROWDED , HOT PLACES
• PRENSENCE OF AUTONOMIC NEUROPATHY OR PARKINSONISM
• ASSOCIATED WITH START OF or INCREASE IN DOSAGE OF
VASODEPRESSIVE DRUGS
• STANDING AFTER EXERTION

12. CARDIOVASCULAR SYNCOPE
• PRESENCE OF DEFINITE STRUCTURAL HEART DISEASE
• FAMILY HISTORY OF SUDDEN UNEXPLAINED DEATH OR
CHANNELOPATHIES
• DURING EXERTION OR SUPINE
• SUDDEN ONSET PALPITATION FOLLOWED IMMEDIATELY BY SYNCOPE
• ECG FINDINGS SUGGESTIVE OF ARRYTHMOGENIC SYNCOPE

13. CARDIAC CAUSES OF SYNCOPE
• ANATOMIC
• OBSTRUCTIVE CARDIAC VALVE DISEASE
• AORTIC DISSECTION
• ATRIAL MYXOMA
• PERICARDIAL TAMPONADE
• MI, PULMONARY EMBOLISM
• ARRHYTHMIAS
• AV BLOCK, SINUS NODE DYSFUNCTION, BRADYCARDIA
• ATRIAL FIBRILLATION, SVT, VT
• HOCM, LONG QT SYNDROME, ARVD, BRUGADA SYNDROME

15. IDENTIFICATION OF HIGH RISK SYNCOPE PATIENTS
• SEVERE STRUCTURAL HEART DISEASE (LOW EF, PREVIOUS MI,
HEART FAILURE)
• CLINICAL FEATURES SUGGESTING ARRYTHMOGENIC SYNCOPE
• SYNCOPE DURING EXERTION OR WHILE SUPINE
• PALPITATIONS AT THE TIME OF SYNCOPE
• CLINICAL EVIDENCE OR SUSPICION OF A PULMONARY EMBOLUS
(SHORTNESS OF BREATH, SINUS TACHYCARDIA, CLINICAL SETTING)
• SEVERE ANAEMIA
• SIGNIFICANT ELECTROLYTE ABNORMALITIES

16. ECG FEATURES SUGGESTING ARRYTHMOGENIC
SYNCOPE
• NON SUSTAINED VT
• QRS > 120 ms;
• SEVERE SINUS BRADYCARDIA (HR< 50) IN THE ABSCENCE OF DRUGS /
PHYSICAL TRAINING
• PROLONGED OR VERY SHORT QT INTERVAL
• PRE EXCITATION
• BRUGADA ECG PATTERN (RBBB WITH STE IN V1 - V3)
• ARRYTHMOGENIC RIGHT VENTRICULAR DYSPLASIA ECG PATTERN
(T WAVE INVERSION IN LEADS V1 - V3 WITH OR WITHOUT EPSILON WAVES)
• ECG SUGGESTIVE OF HYPERTROPHIC CARDIOMYOPATHY

17. DIFFERENTIAL DIAGNOSIS OF SYNCOPE

19. NON SYNCOPAL CAUSES OF TRANSIENT LOC

20. EVALUATION OF
SYNCOPE

22. SYNCOPE VS SEIZURE

23. Recommendations concerning driving in patients with syncope

25. •THANK YOU