Syncope

2,539 views

Published on

Published in: Health & Medicine

Syncope

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

×