Syncope

Question 1

Why isn’t hypoglycemia a good explanation for true syncope?

Answer 1

1. True syncope is caused by complete ischemia to bilateral hemispheres or focal ischemia to RAS
2. Hypoglycemia will have other symptoms. It is not a sudden loss of consciousness with a instant return to baseline

Question 2

Lateral tongue biting is how specific for seizure?

Answer 2

Not sensitive but 97% specific

Question 3

What is the most useful indicator to differentiate syncope from seizure?

Answer 3

Rapid return to consciousness

Question 4

Syncope + CP could be what?

Answer 4

1. ACS
2. PE
3. Dissection

Question 5

Syncope + abdominal pain could be what?

Answer 5

1. AAA

2. Ectopic

Question 6

Syncope + pregnancy could be what?

Answer 6

1. Normal physiology of pregnancy (CV changes)
2. Dehydration
3. Ectopic

Question 7

Syncope + headache could be what?

Answer 7

1. SAH

2. Basilar migraine

Question 8

Syncope + focal neuro symptoms could what?

Answer 8

1. Strokes (but syncope is RARE in strokes–remember, we really need hypoperfusion of both hemispheres)
2. Vertebrobasilar TIA (vertigo, ataxia, diplopia–this can hit RAS)

Question 9

Who needs a head CT for syncope + neuro symptoms?

Answer 9

These are VERY low yield if they don’t have focal findings on their exam

Question 10

Syncope + orthostasis could be caused by what?

Answer 10

1. Hypovolemia
2. Medications
3. Primary autonomic failure

Question 11

Why do you have to be careful about checking orthostatics on all elderly patients with syncope?

Answer 11

The prevalence in the general elderly population is 55%, so you could miss something if you just focus on this

Question 12

What are the two main causes of isolated syncope?

Answer 12

1. Neurocardiogenic

2. Cardiac

Question 13

What is the most common cause of syncope?

Answer 13

Neurocardiogenic (this is a benign process)

**vasovagal syncope

Question 14

What are some provoking factors for neurocardiogenic syncope?

Answer 14

1. Fear, stress, pain, standing

2. Micturition, defacation, standing

Question 15

If history and physical aren’t enough, how can neurocardiogenic syncope be made?

Answer 15

Tilt-table test

Question 16

What are some pharmacologic agents that can be used for neurocardiogenic syncope?

Answer 16

1. Midodrine
2. SSRIs
3. Fludrocortisone
4. B-blockers

Question 17

What EKG findings will be seen in Bruggada syndrome?

Answer 17

RBBB and ST elevation in V1 and V2

Question 18

What symptoms are commonly associated with syncope caused by orthostatic hypotension?

Answer 18

1. Diaphoresis
2. Light-headedness
3. Graying of vision

Question 19

What three rules can be used to help risk stratify syncope patients?

Answer 19

1. San Francisco Syncope Rule
2. OESIL
3. ROSE

Question 20

What are parts of San Francisco Syncope Rule?

Answer 20

1. CHF
2. Abnormal EKG
3. Hematocrit

Question 21

What are parts of ROSE rules?

Answer 21

1. BNP > 300
2. • fecal occult blood
3. Hgb

Question 22

In what groups should near-syncope be evaluated as syncope?

Answer 22

High risk groups

Question 23

What are generally accepted rules regarding prognosis in syncope patients?

Answer 23

1. CHF
2. Structural or coronary heart disease
3. Abnormal EKG

All indicate poor prognosis