Emergency Medicine > Syncope > Flashcards

Syncope Flashcards

(44 cards)

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1
Q

Transient loss of postural tone and consciousness caused by period of inadequate cerebral perfusion. Episodes rarely last >1 minute. Full recovery to baseline mental status without resuscitation, no postictal state

A

Syncope

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2
Q

Prodromal symptom of fainting “I almost fainted”

A

Presyncope

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3
Q

What causes should be at the forefront of syncope/presyncope differential?

A

Cardiac and Neurologic

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4
Q

A patient tells you they have had multiple syncopal events with a new onset. What condition should be considered?

A

AV block

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5
Q

A patient tells you they have had multiple syncopal events over many years. What condition should you be considering?

A

Vasovagal syncope

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6
Q

A patient tells you that they have multiple syncopal episodes daily lasting multiple minutes. What condition should be considered?

A

Psychogenic

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7
Q

A patient has an extended prodrome prior to their syncopal event. What should be considered?

A

Vasovagal syncope

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8
Q

A patient has no prodrome prior to their syncopal event. What cause should be considered?

A

Cardiac causes

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9
Q

A patient tells you their syncopal episodes always occur supine. What are you thinking?

A

Cardiac etiology

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10
Q

A patient tells you that syncopal episodes always occur with change in position. What are you thinking?

A

Orthostatic hypotension (even multiple minutes after change)

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11
Q

A patient tells you that they have syncopal episodes when they are standing upright. What should be considered?

A

Reflex syncope (vasodilation +/- bradycardia

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12
Q

What are provocative factors for reflex syncope?

A
  • Immediately after exercise
  • Defecation or urination
  • Coughing or swallowing
  • Post-prandial
  • Warm and crowded place
  • Prolonged standing
  • Fear, sight of blood, stress
  • Abrupt neck movements
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13
Q

What are possible prodrome symptoms for syncope?

A
  • Lightheadedness
  • Warmth or cold
  • Sweating
  • Palpitations
  • Nausea- abdominal discomfort
  • Blurred vision (blindness possible)
  • Diminished hearing or tinnitus
  • Pallor reported by observers
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14
Q

What are historical factors post syncopal event?

A
  • Continued nausea, pallor, diaphoresis with Reflex syncope
  • True syncope usually 1-2 minutes at most as supine position restores cerebral perfusion
  • Extended syncope- think seizure vs psychogenic
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15
Q

If the “syncopal episode” is actually a seizure, what would witnesses likely see?

A

Eyes open

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16
Q

If a patient has syncope in the presence of a new/severe HA, what should be ruled out?

A

SAH

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17
Q

If a patient has syncope with chest pain or shortness of breath, what should be ruled out?

A

PE, MI, HF

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18
Q

If a patient has syncope with fever, what should be done?

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A
  • Sepsis workup
  • Consider COVID19 infection (this can be only symptom)
19
Q

What conditions are at high risk for syncope due to arrhythmias?

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A
  • CAD
  • Valvular disease
  • Cardiomyopathy
  • Congenital heart disease
  • Previous cardiac surgery
20
Q

What condition places patient at high risk for orthostatic hypotension due to autonomic neuropathy and hypoglycemia?

21
Q

What antibiotics medications can cause QT prolongation that can lead to syncope?

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A

Antibiotics
* Fluoroquinolones
* Macrolides
* Trimethoprim
* Pentamidine
* Azole antifungals

22
Q

What antipsychotic medications can cause long QT leading to syncope?

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A
  • Haloperidol
  • Droperidol
  • Thioridazine
  • Pimozide
23
Q

What antiemetics cause LQTS causing syncope?

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A
  • Ondansetron
  • Granisetron
  • Metoclopramide
24
Q

What antiarrhythmics cause LQTS leading to syncope?

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A

Class IA: Na+ channel blockers
* Quinidine
* Procainamide
* Disopyramide

Class III: K+ channel blockers
* Amiodarone
* Sotalol
* Dofetilidev
* Ibutilide
* Dronedarone

25
What is considered long QT in men? Women? When are you concerned for Torsades?
* Men: >440 * Women: >460 * Torsades: >500
26
What are concerning historical factors for cardiac etiology?
* Absence of prodrome * Event during exertion or supine * Associated with chest pain * Family history of sudden death * Known structural heart disease * Abnormal rhythm history 1 year mortality with cardiac syncope = 30%!
27
If BP very low on pe of syncopal patient, what should you think?
* Sepsis * Cardiac issue * Overdose * Late HF
28
if BP very high on PE of syncopal patient, what should you consider?
* Stroke * HF * Anxiety
29
What PE should be performed on syncopal patient?
* ABCs, vital signs * Complete cardiac exam for murmurs, irregular or bradycardiac rhythms, signs and symptoms of heart failure * Complete neurologic exam: mental status, cranial nerves, motor strength, sensation, gait, reflexes, finger to nose, heel to shin, romberg, pronator drift * Irregular neuro exam --> CT of brain * Evaluate for head and neck trauma if appropriate * Skin turgor/oral mucosa/volume status * Abdominal exam for AAA or rectal exam for GI bleed * Any other historically indicated exam
30
What are irregular or bradycardic rhythms that can cause syncope?
* Afib, significant PVCs * Heart blocks (especially 3rd degree) * Symptomatic bradycardia
31
What are s/s of heart failure?
* Bilateral lower extremity swelling * Increased JVD * S3/S4
32
What diagnostic tests are required for syncope work up?
* EKG * Cardiac monitor throughout stay
33
What syncopal work up can be considered depending on history, age, and risk factors?
* CT brain w/o contrast if head trauma >65, blood thinners, concern for skull fracture, focal neuro def * CBC if poss infection, anemia * Troponin: if considering admission * D Dimer: if concerned for PE and cannot PERC out (CTA of chest with IV contrast if high risk patient * CXR * Orthostatics * FOBT: dark stools, anemia on CBC, cancer hx * HCG: ectopic (any child bearing age female with intact uterus) * UDS
34
What is the disposition of syncopal patients
* Admission allows for cardiology and neurology consult within 24 hours * Consider Risk stratification tool to see outpatient vs inpatient: Canadian Syncope Risk Score or San Francisco Syncope Rule
35
Do not use the canadian syncope calculator if...
* LOC >5 min * Change in mental status * Obvious witnessed seizure * Major trauma/head trauma causing LOC * Intoxication- ETOH or drugs * Language barrier
36
What is the San Francisco Syncope Rule
5 predictors of high risk for serious outcomes at 7 or 30 days 1. CHF history 2. Hct ,30% 3. ECG or cardiac monitoring abnormal 4. SOB history 5. SBP <90 mmHg at triage ## Footnote CHESS
37
What are types of reflex syncope?
* Vasovagal * Situational * Carotid sinus syncope
38
What is reflex syncope?
* Vasodilation and/or bradycardia causing systemic hypotension and cerebral underperfusion
39
What is the epidemiology of vasovagal syncope
MC cause of syncope in all ages 60% of patients with a heart condition and syncope diagnosed with vasovagal syncope
40
Presentation of vasovagal syncope
Prodrome usually present * Pale skin * Nausea * Feeling warm * Cold sweat * Blurred vision * Classic presentation: donating or seeing blood, emotional upset * After vigorous exercise in athletes * In sitting or standing position * Post episode fatigue possible (but not in cardiac induced)
41
PE of vasovagal syncope
No cardiac or neuro abnormalities
42
Workup of vasovagal syncope
* EKG: usually normal or non-specific * Strong history: episode + previous medical history * Other investigations as indicated from history * Often diagnosis of exclusion after careful history and negative workup
43
Disposition of vasovagal syncope
* Evaluated with risk evaluation device * Low risk and moderate risk may be discharged home with follow-up with primary care * High risk admitted
44
What is reflex syncope?
* Failure of sympathetic efferent vasoconstrictor
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