{"id":5305,"date":"2011-07-14T20:25:20","date_gmt":"2011-07-14T20:25:20","guid":{"rendered":"http:\/\/crashtext.org\/misc\/5305.htm\/"},"modified":"2015-03-26T00:16:26","modified_gmt":"2015-03-26T04:16:26","slug":"syncope","status":"publish","type":"post","link":"https:\/\/crashingpatient.com\/medical-surgical\/cardiology\/syncope.htm\/","title":{"rendered":"Syncope"},"content":{"rendered":"

Syncope From Greek meaning pause \u00a0
\nAmal Mattu Article on EKG findings to check for all syncope patients<\/a><\/p>\n

Strayer-Tainter Syncope Sheet<\/a><\/p>\n

My EKG <\/a>
\nMy EKG Sheet<\/a><\/p>\n

Cardiac Causes Obstruction to flow \u0095 Subaortic stenosis \u0095 Aortic valve stenosis \u0095 Mitral valve stenosis \u0095 Atrial myxoma (rare) \u0095 Pulmonic valve stenosis \u0095 Hypertrophic cardiomyopathy \u0095 Dilated cardiomyopathy \u0095 Restrictive cardiomyopathy \u0095 Pericardial tamponade \u0095 Severe congestive heart failure Vascular disease \u0095 Pulmonary emboli \u0095 Pulmonary hypertension \u0095 Acute myocardial infarction \u0095 Air embolism \u0095 Aortic dissection\/leaking aortic aneurysm \u0095 Subclavian steal syndrome Dysrhythmias Tachydysrhythmias \u0095 Supraventricular tachycardia \u0095 Ventricular tachycardia \u0095 Ventricular fibrillation \u0095 Atrial fibrillation with fast conduction \u0095 Wolff-Parkinson-White syndrome \u0095 Prolonged QT syndrome \u0095 Brugada syndrome Bradydysrhythmias \u00a0 \u0095 Atrioventricular block \u0095 Atrial fibrillation with slow conduction \u0095 Sick sinus syndrome \u0095 Pacemaker malfunction Noncardiac Causes \u00a0 Vasodepressor (vasovagal, neurocardiogenic) \u0095 Situational \u0095 Micturition \u0095 Post-tussive \u0095 Swallow \u0095 Defecation \u0095 Valsalva (weightlifters) \u0095 Carotid sinus sensitivity Orthostatic \u0095 Anemia\/GI bleed \u0095 Dehydration Central nervous system \/ neurologic \u0095 Seizure (excluded by most syncope studies) \u0095 Neuralgias (trigeminal, glossopharyngeal) \u0095 Neurologic (TIA, strokes, migraines [rare]) \u0095 Subarachnoid hemorrhage \u0095 Subdural\/epidural hemorrhage Metabolic \/ toxic \u0095 Hypoglycemia \u0095 Hypoxia \u0095 Drug-induced \u0095 Carbon monoxide poisoning \u0095 Chemical \/ toxic gas exposure \u0095 Carotid sinus sensitivity \u0095 Infectious agent Psychogenic \u0095 Somatization disorder \u0095 Anxiety disorder \u0095 Conversion disorder \u0095 Panic disorder \u0095 Hyperventilation \u0095 Breath-holding spells \u00a0 \u00a0 Causes of collapse2 Differential diagnosis Clinical clues<\/p>\n

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H<\/strong>ypoxia, hypoglycaemia Should be picked up in primary survey Do not forget the glucose E<\/strong>pilepsy* Previous history, postictal period A<\/strong>ffective (psychological) History of anxiety or panic disorder, hyperventilation D<\/strong>ysfunction of brain stem\u0097for example, vertebrobasilar transient ischaemic attack, basilar migraine Cerebellar signs on neurological examination H<\/strong>eart\u0097for example, ischaemic heart disease Recent chest pain, history of myocardial infarction E<\/strong>mboli\u0097pulmonary embolism Pleuritic chest pain, dyspnoea, calf pain, or swelling A<\/strong>ortic obstruction\u0097for example, stenosis, hypertrophic obstructive cardiomyopathy (HOCM) Precipitated by exertion, cardiac murmur on auscultation R<\/strong>hythm disorders\u0097for example, sick sinus syndrome, complete heart block May be picked up on primary survey if heart rate <50, history of ischaemic heart disease T<\/strong>achydysrhythmias\u0097for example, SVT, VT, long QT syndrome History of palpitations, may be picked up on primary survey if heart rate >100, <5 s prodromal period V<\/strong>asovagal* Prodrome of nausea, dizziness, yawning, sweaty E<\/strong>NT\u0097for example, M\u00e9ni\u00e8re\u0092s disease, acute labyrinthitis, benign paroxysmal positional vertigo History of vertigo, deafness, tinnitis. nystagmus on neurological examination S<\/strong>ituational\u0097for example, fright, micturition, deglutition, defaecation May be apparent from history S<\/strong>ensitive carotid sinus Precipitated by head movement E<\/strong>ctopic pregnancy** History of abdominal pain, amenorrhoea, PV bleeding, positive pregnancy test L<\/strong>ow vascular tone S<\/strong>ubclavian steal** Precipitated by upper arm exertion DRUGS<\/strong>\u0097for example, antihypertensives, sympathetic blockers causing postural hypotension* Elderly patient on multiple drugs Postural fall in blood pressure<\/p>\n

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*Common causes \u00a0 \u00a0 \u00a0 In seconds preceding LOC there is a loss of lateral gaze, possibly dizziness Vascular\/Cardiac-rhythmic, obstructive, metabolic, meds Vasomotor-consider AAA, ectopic, and other sources of occult bleeding Cardiac-if exercise induced, think IHSS, valvular disorder, or subclavian steal Stokes-Adams: heart block, syncope, vertigo Cough, micturition, post-prandial Place pregnant women in LLR \u00a0 High risk if >60 y\/o or Cardiac history CHF on exam assoc. c high risk \u00a0 12 Lead EKG (even in the young for prolonged QT and Brugada), consider CBC or guiac and pregnancy test. Admit high risk or young pts c syncope during exercise (ACEP Clinical Guidelines) Neurally Mediated Syncope associated with inappropriate vasodilatation, bradycardia or both. a. Vasovagal syncope is often associated with a sensation of increased warmth and may be accompanied by nausea. It may occur after exposure to an unexpected or unpleasant sight, sound or smell, fear, severe pain, emotional distress and instrumentation. It may also occur in association with prolonged standing or kneeling in a crowded or warm place or on exertion (all three latter scenarios may also be due to autonomic failure) b. Situational syncope occurs during or immediately after coughing, micturition, defecation or swallowing. Syncope associated with throat or facial pain, however, may be due to glossopharyngeal or trigeminal neuralgia c. Carotid sinus syncope can be associated with neck pressure (shaving, tight collar) or head turning Orthostatic Syncope Occurs when there is documented hypotension associated with syncopal or presyncopal symptoms. According to ECS guidelines, orthostatic blood pressures are recommended to be taken after five minutes of being supine. A decrease of more than 20mm Hg in the systolic pressure is considered abnormal as is a drop in pressure below 90mm Hg independent of the development of symptoms. Neurologic Syncope Neurologic causes of apparent syncope include seizures, TIAs, migraine headaches and subclavian steal syndrome. Confusion after “syncope” that lasts more than five minutes, tongue biting, incontinence, epileptic aura suggest this diagnosis. A significant differential in the blood pressure of the two arms suggests subclavian steal Cardiac-Related Syncope The major categories of cardiac disease associated with syncope are ischemia, valvular<\/p>\n

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and arrhythmic. Accuracy and Quality of Clinical Decision Rules for Syncope in the ED A MA (Ann Emerg Med 2010;56(4):362)<\/p>\n

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QT syndrome suggested by notched or bifid T waves in V2-V4 \u00a0 Risk Stratification for Syncope Martin et al 252 derivation, 374 validation<\/p>\n