MRCEM OSCE > Cases | Syncope > Flashcards

Cases | Syncope Flashcards

(39 cards)

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1
Q

What is the definition of syncope?

A

TLOC with spontaneous recovery

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2
Q

What are the priorities/key questions in treating syncope in the ED?

A
  • Life threats?
  • Need for admission?
  • Discharge with follow-up?
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3
Q

What are the main differentials in syncope?

A

VAPE

  • Vasovagal
  • Arrhythmogenic/Cardiogenic
  • Postural hypotension
  • Epilepsy/Neurogenic
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4
Q

What are the potential vasovagal triggers of syncope?

A
  • Cough
  • Micturition
  • Defecation
  • Stress
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5
Q

What are the potential cardiogenic causes of syncope?

A
  • Bradycardia/Tachycardia. Bradycardia can be post-op from valve replacement (sAVR/TAVI)
  • Obstructive lesion - AS, MS, HOCM, PH
  • Lyme
  • Sarcoid
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6
Q

What are the potential postural triggers of syncope?

A

Vasodilators
* ACEi/ARBs
* BBs
* GTN
* Sildenafil

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7
Q

What are the potential neurogenic triggers of syncope?

A
  • Epilepsy/NEAD
  • Vertebrobasilar insufficiency
  • ETOH
  • Diabetes
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8
Q

What are the life threats in syncope?

A
  • Neuro - SAH
  • Resp - Massive PE
  • Cardiac - Aortic/carotid dissection
  • GI/GU - Ruptured ectopic/GI bleed
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9
Q

What are the other causes of syncope outside the VAPE acronym?

A
  • MSA
  • Sarcoidosis
  • Lyme disease
  • Diabetes
  • Alcohol
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10
Q

What is an oft erroneously attributed cause of syncope?

A

TIA. Consider posterior TIA.

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11
Q

Can you name the six P’s of syncope history taking?

A
  • Position/postural
  • Prodrome
  • Precipitant
  • Perk-up (recovery)
  • Pain (injuries)
  • Previous falls
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12
Q

What are the 3 P’s that indicate a benign cause of syncope?

A
  • Prodrome
  • Postural
  • Precipitant
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13
Q

What are the key factors to consider in drug history of syncope?

A
  • Vasodilators
  • Compliance with medications such as AEDs and insulin
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14
Q

What are the key factors to consider in family history?

A

Epilepsy

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15
Q

What are the key factors to consider when exploring social history in syncope?

A
  • Driving
  • Heavy machinery
  • Water immersion
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16
Q

What is an appropriate examination to undertake for syncope?

Study These Flashcards
A
  • Focused cardiology exam
  • Focused neurology exam
  • CLD & diabetes
17
Q

What are the elements of the cardio exam that are important to consider?

Study These Flashcards
A
  • L&S BP - postural >20/10
  • Auscultation - AS, MS, loud P2, parasternal heave
  • Pacemaker/ICD scars
18
Q

What are the elements of the neuro exam that are important to consider?

Study These Flashcards
A
  • Pronator drift
  • UMN signs
  • Fundoscopy e.g. papilloedema diabetic retinopathy
  • Parkinsonism (TRAP)
19
Q

What are the bedside investigations that can be undertaken in syncope?

Study These Flashcards
A
  • Lying and Standing BP
  • 12 lead ECG
  • Bloods - haematology and metabolic panel, CRP, glucose
20
Q

What are the special investigations that can be undertaken to investigate cardiac syncope?

Study These Flashcards
A
  • Holter monitor
  • Implantable loop recorder
  • Electrophysiological studies
  • Echo
  • Tilt table test in orthostatic HTN
21
Q

What are the special investigations that can be undertaken to investigate neurogenic syncope?

Study These Flashcards
A
  • EEG
  • CT/MRI Brain
22
Q

What is the management for vasovagal causes of syncope?

Study These Flashcards
A
  • Hydration and increased salt intake
  • Compression stockings
23
Q

What is the management for cardiogenic causes of syncope?

Study These Flashcards
A

Rhythm & Blues
* PPM/ICD
* Revascularisation and valvular surgery

24
Q

What is the management for postural causes of syncope?

Study These Flashcards
A
  • Hydration and increased salt intake
  • Compression stockings
  • Fludrocortisone (mineralcorticoid) and midodrine (alpha agonist)
25
What is the management for neurogenic causes of syncope?
* AEDs * Avoid triggers - sleep, stress, smoking, alcohol * Safety - heavy machinery, driving
26
What are the different categories of seizures in epilepsy?
*Generalised* * Tonic clonic * Absence * Atonic - altered conscious state *Partial* * Simple - patient aware * Complex - staring blankly, daydreaming, may have seocndary generalisation
27
What elements of seizures are suggestive of epilepsy?
2 or more unprovoked seizures >24 hours apart.
28
What percentage of seizures have no causes found?
2/3
29
What are the different elements of Multiple System Atrophy?
MSA-P - Tremor, Rigidity, Akinesia MSA - C - Cerebellar ataxia and autonomic dysfunction
30
What are the elements of autonomic dysfunction?
* Collapse * Dry mouth * Hoarse voice * Swallowing difficulty * Urinary retention * Impotence
31
What are the elements of Lyme Disease?
* Deer tick bite - Borrelia Burgdorferi * Erythema migrans - bullseye rash * Lyme carditis - 1 in 100. AV block. Chest pain, syncope, SOB. * Fatigue, fever, arthralgia * Diagnosis - detect antibody via ELISA and Western Blot few weeks after infection * Treatment = Doxycycline
32
What are the DVLA guidelines for syncope?
* Solitary with clear treated cause = 4 weeks * Solitary with no clear cause = 6 month ban * Recurrent syncope secondary to seizures = 1 year seizure free
33
What are the broad differentials for falls in the elderly?
* Trip/stumble * Dizzy spell * Medical collapse
34
What are the potential consequences of a long lie?
* Hypothermia * Hypovolaemia * Trauma - pressure sores and rhabdomyolysis (increased potassium and AKI)
35
What are the injuries that could result from falls in the elderly?
* Pelvis fractures - NOF, Pubic ramus, head & neck trauma
36
When is discharge safe to consider in syncope?
Full recovery and normal exam with history suggestive of vasovagal.
37
When should OP ECG monitoring/investigations take place in unexplained syncope?
>65 with unexplained syncope.
38
What are the red flag features of cardiogenic syncope?
* LOC on exertion * Unexplained SOB * Family history of cardiac issues * Heart Failure * Heart Murmur * ECG abnormality
39
What features of syncope should indicate that patient should be treated as "first fit"?
1) Aura 2) Abnormal movements * Prolonged jerking * Abnormal posturing * Head turned to one side * Bitten tongue * Post-ictal confusion
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