MCC of Syncope
- Vasovagal (neurocardiogenic)
- Idiopathic
- Orthostatic HypoTN
Cardiovascular problems that reduce CO
- obstructed outflow of the heart (aortic stenosis, cardiomyopathy, tamponade, PE)
- systolic or diastolic dysfn
- Arrhythmias (tach >150 or Brady <35)
- decreased venous return
Syncope causes to r/o
- Cerebrovascular DO (TIA, CVA)
- Migraine
- Positional Vertebrobasilar insufficiency (positional syncope when moving head in certain positions due to cervical arthritis, spondylosis, or wearing neck ties or tight collars)
- Hypoglycemia
When someone passes out, you need to r/o causes that involve the _____, ______, & ______
Heart, Brain, Sugar
Syncope Hx Qs
- What were you doing before it happened?
- What position were you in when it happened? (standing, sitting?)
- How long were you unconscious?
- Complete recovery or sequelae?
- How many times has this happened?
- Associated symp? sense of impending loss of consciousness, nausea, sweating, blurred or tunnel vision, tingling of lips or fingertips, CP, palpitations?
Meds that incr risk of syncope
- Diuretics
- BBs
- Vasodilators
- Antiarrhythmics
- Nitrates
- CCBs
- Digoxin
- Fluorquinolones
- Antipsychotics
- Antidepressants
- Antihistamines
- Some chemo
What can make a syncope case very concerning?
- Syncope during exertion = cardiac!
- Syncope while laying down = Cardiac, Arrhythmia
- Multi recurrances within short time
- Heart murmur, CP, palpitations
- Older age
- Significant injury during syncope = Cardiac, Szs
- FMH of sudden unexpected death, exertional syncope, or unexplained recurrent syncope or seizures
WU for syncope
- EKG for EVERYONE
- Pulse Ox
- Labs as per symp (CMP for e-, CBC for anemia, Preg test, Cardia cpanel, drug screen)
- Echo/stress test
- Tilt test
- EEG/Brain imaging
Adult pt presents with bradycardia, LOW BP, and confusion. EKG confirms bradyarrhythmia. Wdyd?
Give Atropine 1mg Bolus
If atropine is innefective:
- Transcutaneous pacing And/or
- Dopamine or Epi infusion
Adult pt presents with bradycardia and EKG confirmed bradyarrhythmia. Norm BP. No signs of altered mental status, shock, ischemic chest discomfort, or acute HF. Wdyd?
Monitor and observe
Adult pt presents with Tachycardia, Pulse, LOW BP, and confusion. EKG confirms tachyarrhytmia. Wdyd?
Synchronized Cardioversion
Consider Sedation
If regular narrow complex, consider Adenosine
Adult presents to ED with Tachycardia and a pulse. However, BP is norm and there are no signs of altered mental status, shock, acute HF, or ischemic chest discomfort. EKG confirms Tacchyarrhythmia and Wide QRS (>0.12sec). Wdyd?
- Adenosine only if regular and monomorphic
- Antiarrhythmic infusion
- Expert consult
Adult presents to ED with Tachycardia and a pulse. However, BP is norm and there are no signs of altered mental status, shock, acute HF, or ischemic chest discomfort. EKG confirms Tacchyarrhythmia and NARROW QRS (< 0.12sec). Wdyd?
- Vagal maneuvers (if regular)
- Adensoine (if regular)
- BBs or CCBs
- Consider expert consult
