Syncope

Question 1

common in who?

Answer 1

elderly, increases w/ age

Question 2

high risk features

Answer 2

1. hx of structural heart disease
2. abnormal EKG
3. > 60 y/o

Question 3

most common cause of syncope?

Answer 3

vasovagal

Question 4

prognosis is favorable unless there is what?

Answer 4

accompanying cardiac disease

Question 5

what is neurally mediated syncope?

Answer 5

• syncope due to excessive vagal tone or impaired reflex control peripheral circulation

Question 6

3 types of neurally mediated syncope

Answer 6

1. vasovagal syncope
2. carotid sinus hypersensitivity
3. situational syncope

Question 7

neurally mediated syncope

what is vasovagal syncope caused by typically?

Answer 7

caused by a stressful, painful, or claustrophobic experience

Question 8

neurally mediated syncope

what is carotid sinus hypersensitivity caused by?

Answer 8

stimulation of abnormally sensitive carotid body, with subsequent abnormal vagal response

Question 9

neurally mediated syncope

what does carotid sinus hypersensitivity result in?

Answer 9

• bradycardia
• arterial relaxation/dilation

Question 10

neurally mediated syncope

pathophys of situational syncope?

Answer 10

enhanced vagal tone w/ resulting hypotension

Question 11

neurally mediated syncope

what causes situational syncope?

Answer 11

• coughing
• sneezing
• micturition
• exercise

Question 12

Orthostatic/Postural Hypotension

describe

v basic

Answer 12

• BP drops upon standing

Question 13

Orthostatic/Postural Hypotension

common in who?

4 groups of pts

Answer 13

• pts with autonomic neuropathy
• blood loss/hypovolemia
• pts taking vasodilators, diuretics, adrenergic-blocking medications
• more common in elderly pts

Question 14

Orthostatic/Postural Hypotension

pathophys

Answer 14

failure of the vasoconstrictive response to changing to an upright position

Question 15

Orthostatic/Postural Hypotension

when are sx most likely to occur?

Answer 15

• in the early morning
• after heavy meals
• w/ prolonged standing
• when core body temp rises

Question 16

Orthostatic/Postural Hypotension

who does chronic idiopathic orthostatic hypotension primarily exist in?

Answer 16

older men

Question 17

Cardiogenic Syncope

causes of this if bradycardic?

3

Answer 17

• sinus brady
• sinus pauses
• AV blocks

Question 18

Cardiogenic Syncope

causes of this is tachycardic?

Answer 18

ventricular tachycardia

Question 19

Cardiogenic Syncope

causes of this is mehicanical?

4

Answer 19

• aortic/pulm stenosis
• hypertrophic CM
• congenital lesions
• massive PE

Question 20

common presyncope sx

9

Answer 20

1. lightheadedness
2. unstable when standing
3. warm or cold/clammy
4. diaphoretic
5. palpitations
6. n/v/abd pain
7. visual blurring or “white out”
8. diminution of hearing and/or occurence of unusal sounds
9. pallor

Question 21

Essential History Questions

5

Answer 21

• what happened right before the event? (what were you doing/sx that happened)
• were you injured when you fell?
• did you lose consciousness?
• how long did it take to “feel normal” following the event?
• did anyone witness the event?

Question 22

events longer than ??? are genereally not considered syncope?

Answer 22

than 5 min

Question 23

which drugs can cause syncope?

8

Answer 23

1. anti-hypertensives
2. BBs
3. anti-arrhythmics
4. anti-parkinson drugs
5. anti-depressants
6. phenothiazines
7. nitrates
8. cocaine/alcohol

Question 24

PE Components

5

Answer 24

1. orthostatic vital signs (determine etiology)
2. heart rate + rhythm
3. respiratory rate
4. cardio exam
5. neruo exam

Question 25

key neuro components to include:

Answer 25

* strength, reflex, pronator drift * ambulate the patient

Question 26

what testing to consider for reflex syncope

Answer 26

* ambulatory EKG

Question 27

testing to order w/ cardiogenic syncope

Answer 27

* cardio exam * ambulatory EKG * echo * cardiac imaging

Question 28

testing to order w/ orthostatic syncope?

Answer 28

* IV fluids * stop offending meds

Question 29

typical syncope workup | 8

Answer 29

* unremarkable H&P * absence of cardiac disease * absence of significant comorbidities * normal baseline EKG * echo * routine cardiac imaging PRN * carotid artery imaging PRN * routine comprehensive lab testing not useful

Question 30

which syncopial features are low risk? | 7

Answer 30

* prodrome sx * after sudden unexpected sight, sound, smell, or pain * after prolonged standing, crowding, or hot places * during a meal/postprandial * triggered * w/ head rotation or pressure on carotid sinus * standing up from supine position

Question 31

which syncopial features are high risk? | 4

Answer 31

* new onset of CP, breathlessness, abd pain, or HA * syncope on exertion or when supine * sudden onset palpitation followed by syncope * EKG changes consistent w/ ischemia

Question 32

reflex/vasovagal management | 5

Answer 32

* trigger avoidance * avoid fluids, salt * compression socks (to increase flow) * counterpressure maneuvers * pharm tx or pacemaker if severe

Question 33

# reflex/vasovagal management describe counterpressure maneuvers

Answer 33

* leg: crossing w/ simultaneous tensing of leg, abd, and buttock muscles * handgrip: max grip on something * arm tensing: hands together, simultaneously abduct both arms

Question 34

describe orthostatic hypotension syncope management | 8

Answer 34

* avoiding physical deconditioning in the elderly * external compression devices * physical maneuvers (squats, lunges, etc) * review of home meds * discontinue diuretics/vasodilators * increase water/fluid intake, increase salt * sleep at 10deg elevation * avoid hot showers, spas, hot tubs, saunas

Question 35

orthostatic hypotension syncope med goal

Answer 35

increase blood volume

Question 36

orthostatic hypotension syncope med options

Answer 36

* midodrine * fludrocortisone * pyridostigime * yohimbine * octreotide * cafergot (caffeine, erotamine)

Question 37

cardiogenic syncope management

Answer 37

* tx of underlying cardiac disorder

Question 38

education to provide

Answer 38

driving restrictions