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Yr 4 - OSCE Stations > History: LOC > Flashcards

History: LOC Flashcards

1
Q

What are the 3 major criteria for syncope?

A

1) Loss of consciousness: an initial loss of postural tone (going floppy) is a good indication of this.

2) LOC must be transient (i.e. self-limiting - excludes events such as cardiac arrest and hypoglycaemic coma which do not normally involve spontaneous recover)

3) Caused by global cerebral hypoperfusion, which almost always means a reduction in blood pressure.

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2
Q

What characteristics point to a syncopal episodes?

A
  • rapid onset
  • short duration (typically <20 seconds)
  • spontaneous and complete recovery (although some disorientation is common with increasing age)
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3
Q

Questions to ask about ‘before’ the syncopal event ?

A

1) Triggers e.g. emotion, pain, exercise

2) Prodrome/’pre-syncope’ e.g. light-headed, dizzy, vertigo, nausea, sweating, tinnitus, visual disturbances

3) Change colour - pallor (occurs from systemic hypotension)

4) Any concurrent illnesses or infections

5) What were they doing before?

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4
Q

What does the presence of palpitations or other cardiac symptoms prior to syncope indicate?

A

A cardiac cause of syncope

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5
Q

What does cyanosis prior to LOC indicate?

A

A blue colour (cyanosis) occurs from transient loss of respiratory muscle action in any seizure beginning with a tonic phase (e.g. generalised tonic-clonic seizure).

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6
Q

Questions to ask about ‘during’ the syncopal event ?

A

1) Was it witnessed?

2) Do they remember falling?

3) How long did LOC last?

4) Was there a convulsion?

5) Tongue biting or incontinence?

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7
Q

Questions to ask about ‘after’ the syncopal event ?

A

1) Who found them?

2) How did they get up/get to doctors?

3) Length of LOC?

4) Length of lie?

5) How long did it take for full recovery?

6) Confusion or drowsiness?

7) Pain or injuries (ask about head trauma, especially if on blood thinners)

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8
Q

What is reflex syncope?

A

A general term used to describe types of syncope resulting from a failure in autoregulation of blood pressure, and ultimately, in cerebral perfusion pressure resulting in transient LOC.

E.g. Vasovagal syncope, situational syncope, carotid sinus hypersensitivity.

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9
Q

What are 2 triggers for vasovagal syncope?

A

1) Emotional distress (e.g. fear, pain, instrumentation, blood phobia)

2) Orthostatic stress (e.g. prolonged standing).

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10
Q

What are some triggers for situational syncope?

A

Cough, sneeze, defecation, micturition, exercise and eating (post-prandial).

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11
Q

What are some triggers for carotid sinus hypersensitivity?

A

Shaving, tight-fitting collars and sudden turning of the head.

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12
Q

What is LOC triggered by physical exertion often associated with?

A

CVS syncope e.g. aortic stenosis, arrhytmia

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13
Q

What is LOC triggered by going from sitting to standing often associated with?

A

orthostatic hypotension (e.g. hypovolaemia, autonomic failure).

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14
Q

What is LOC triggered by working with arms elevated about head often associated with?

A

subclavian steal syndrome

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15
Q

What is subclavian steal syndrome?

A

A rare condition causing syncope or neurological deficits when the blood supply to the affected arm is increased through exercise.

Subclavian steal is 2ary to a proximal stenosing lesion or occlusion in the subclavian artery, typically on the left.

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16
Q

Vasovagal syncope is often preceded by prodromal symptoms.

Give some examples

A

1) Progressive light-headedness

2) Visual disturbances (dimming of vision or loss of vision)

3) Weakness or sensory disturbances of the extremities

4) Sweating

5) Nausea

6) Tinnitus

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17
Q

Describe fall in vasovagal syncope vs CVS syncope

A

Vasovagal - patient typically demonstrates a slow, controlled collapse towards the ground

CVS - involves a sudden uncontrolled fall to the ground

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18
Q

Prodromal symptoms in CVS syncope vs vasovagal syncope?

A

CVS syncope often lacks any prodromal symptoms, with the patient feeling ok and then losing consciousness suddenly with no warning.

CVS syncope may cause cardiac symptoms prior e.g. palpitations, chest pain (2ary to arrhythmia).

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19
Q

Generalised seizures can begin with epileptic auras or focal motor/sensory seizures.

What symptoms can this cause?

A
  • Olfactory or gustatory hallucinations (e.g. a specific smell or taste)
  • Visual hallucinations (e.g. flashing lights or blurring of vision)
  • A sense of déjà-vu
  • Sensory disturbances (e.g. numbness, tingling)
  • Motor weakness (e.g. unilateral limb weakness, twitching)
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20
Q

Once it has been established syncope has occurred, there are two important aims for further assessment.

What are they?

A

1) Determine the underlying cause, in the hope of providing treatment and preventing further events

2) Ascertain their risk of further events

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21
Q

What are the 4 classifications of syncope?

A

1) Structural (potentially life-threatening)

2) Arrhythmic (potentially life-threatening)

3) Neurally mediated (typically benign)

4) Postural (typically benign)

Use mneumonic - SNAP.

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22
Q

What is neurally mediated syncope?

A

Due to an inappropriate autonomic reflex in response to a trigger (also known as reflex syncope).

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23
Q

What is the most common type of syncope?

A

Vasovagal

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24
Q

What are the 3 types of neurally mediated syncope?

A

1) Vasovagal

2) Situational

3) Carotid sinus hypersensitivity

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25
Q

What type of situational syncope is a red flag?

A

Post-exercise syncope - must be investigated further to rule out a structural cardiac cause

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26
Q

Causes of vagovagal syncope?

A

It is common in young people following emotional response, such as fear, anxiety or disgust, but may also happen due to prolonged standing.

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27
Q

What is situational syncope?

A

Situational syncope occurs when syncope occurs consistently after a specific trigger.

28
Q

Causes of situational syncope?

A

Post-micturition (the most common)
Post-cough
Post-swallow
Post-defecation
Post-prandial
Post-exercise*

29
Q

What is the most common type of situational syncope?

A

Post-micturition

30
Q

Who is post-micturition common in?

A

Micturition syncope is most common in older men and usually when getting up at night from a deep sleep

31
Q

What is carotid sinus hypersensitivity?

A

This involves syncope after mechanical manipulation of the carotid sinus, which can happen accidentally whilst shaving, wearing a tight shirt collar or even head movement (e.g. looking over shoulder).

32
Q

What are the important areas to cover in the history in neurally mediated syncope?

A

1) Precipitant/trigger: if situational, ask if the trigger consistently causes syncope

2) Warning symptoms: classic pre-syncopal symptoms of nausea, sweating, feeling faint

3) Position: vasovagal syncope usually happens when standing

4) If there is no underlying cardiac disease, a typical history is enough to diagnose reflex syncope.

33
Q

Relevant investigations for neurally mediated syncope?

A

1) Lying and standing BP

2) Tilt table testing: recreates trigger/situation while measuring BP and other signs to confirm the diagnis

3) Carotid sinus massage

34
Q

What does postural (orthostatic) syncope result from?

A

Insufficiency of the baroreceptor response, resulting in syncope.

35
Q

What are some causes of orthostatic hypotension

A

1) Autonomic nervous failure 2ary to drugs

2) Hypovolaemia: may be a sinister underlying cause such as a GI bleed.

3) Primary autonomic nervous failure

4) Secondary autonomic nervous failure

36
Q

What is the commonest cause of orthostatis hypotension?

A

Autonomic nervous failure secondary to drugs

37
Q

What are some common drugs that can cause orthostatic hypotension

A
  • antihypertensives
  • diuretics
  • TCAs
  • antipsychotics
  • alcohol
38
Q

What conditions cause 1ary autonomic nervous failure that can lead to orthostatic hypotension?

A
  • Parkinson’s
  • Lewy body dementia
  • Multiple system atrophy
39
Q

What conditions 2ary autonomic nervous failure that can lead to orthostatic hypotension?

A

Occurs secondary to other conditions such as diabetes, uraemia and spinal cord lesions.

40
Q

What are important areas in the history to cover for postural (orthostatic) syncope?

A

1) Position: clear association with standing

2) Prodrome: may be prolonged in delayed postural syncope

3) DH

3) Any cause for hypovolaemia: haemorrhage, diarrhoea, vomiting, burns

4) PMH: anything that could result in failure of the autonomic nervous system (e.g. diabetes)

41
Q

Both bradyarrhythmias and tachyarrhythmias can case syncope.

Which is more likely?

A

Bradyarrhythmias are more likely to cause syncope.

42
Q

what is it always important to ask about in a potential arrhythmic syncope history?

A

1) FH of sudden death –> can indicate a potentially fatal disease such as a familial channelopathy (e.g. long QT syndrome, Brugada syndrome) or cardiomyopathy (e.g. hypertrophic cardiomyopathy).

2) PMH - consider pacemaker dysfunction

43
Q

What are 3 types of bradyarrythmias that can cause syncope?

A

1) Sick sinus syndrome

2) 2nd degree AV block

3) 3rd degree (complete) AV block

In each case, there is either failure of impulse initiation by the sinus node (sick sinus syndrome) or impulse conduction to the ventricles.

44
Q

What causes the reduction in BP responsible for the syncope in bradyarrythmias?

A

This reduction occurs when there is a long pause (usually >3 secs) between the impulse conduction failure and the ectopic escape mechanism.

45
Q

What type of tachyarrhythmia is most likely to cause syncope?

A

VT

46
Q

What must be ruled out when anyone presents with ventricular tachycardia?

A

Pre-existing structural cardiac disease —> VT is most commonly occurs in individuals with pre-existing structural cardiac disease

47
Q

What can cause VT?

A

1) pre-existing structural cardiac disease

2) long QT syndrome (can cause torsades de pointes - a specific type of VT)

48
Q

What are structural causes of syncope usually due to?

A

Mechanical obstruction in the left ventricular inflow or outflow tract.

49
Q

How can obstruction in the left ventricular inflow or outflow tract cause syncope?

A

Normally during exertion, systemic vasodilatation occurs in order to increase perfusion to skeletal muscle, and the reduction in BP is compensated for by an increased stroke volume and HR.

However, when there is an obstruction to outflow, this compensation does not happen and exertional syncope can occur due to a reduction in BP during exercise.

50
Q

Post-exertional syncope vs structural syncope?

A

Post-exertional syncope as a neurally mediated reflex normally occurs AFTER exercise.

Syncope from outflow tract obstruction occurs DURING exercise.

51
Q

Causes of structural syncope in younger patients vs older patients?

A

Younger - more likely to have inherited causes (e.g. hypertrophic cardiomyopathy

Older - more likely to have acquired causes (e.g. aortic stenosis) and present readily with other symptoms such as breathlessness, fatigue, low exercise tolerance and/or peripheral oedema.

52
Q

What are some causes of structural syncope?

A

1) Valvular disease (e.g. aortic stenosis)

2) Cardiac masses (e.g. atrial myxoma)

3) Cardiomyopathy (e.g. hypertrophic cardiomyopathy)

4) Pericardial disease (e.g. constrictive pericarditis)

5) Non-cardiac causes (e.g. pulmonary embolism, aortic dissection)

53
Q

What are some important areas to cover in the history for arrhythmic and structural syncope?

A

1) Palpitations

2) Other cardiac symptoms (e.g. chest pain, breathlessness, oedema)

3) No prodromal warning (unlike in reflex and orthostatic syncope, where there are clear pre-syncopal symptoms)

4) Onset when sitting or lying down

5) Onset with exercise (clarify if it is after or during exercise)

6) Presence of any previous heart disease including myocardial infarctions, surgeries, and any cardiac device details (pacemakers and ICDs)

7) DH

8) FH of sudden cardiac death

54
Q

Relevant investigations for arrhythmic and structural syncope?

A

1) Resting 12-lead ECG

2) ECG monitoring

3) ECHO

55
Q

What may an ECG show in arrhythmic and structural syncope?

A
  • evidence of ischaemic heart disease (e.g. pathological Q waves)
  • long QT interval
  • Wolff-Parkinson-White syndrome
56
Q

Purpose of ECG monitoring in arrhythmic and structural syncope?

A

Can be used to confirm an association between syncope and the arrhythmia –> this is the only way to definitively diagnose arrhythmic syncope.

57
Q

What may an ECHO show in arrhythmic and structural syncope?

A
  • heart failure
  • cardiomyopathies
  • valvular disease
  • non-cardiac disease (e.g. pulmonary hypertension)
58
Q

What are the 5 P’s to remember for syncope history taking?

A

Precipitant
Prodrome
Position
Palpitations
Post-event phenomena

59
Q

What are the 5 C’s to remember for syncope history taking?

A

Colour
Convulsions
Continence
Cardiac problems
Cardiac death family history

60
Q

What are some examples of symptoms you could screen for in each system in syncope?

A

Systemic: fevers (e.g. cerebral abscess, meningitis), weight change (e.g. malignancy)

CVS: palpitations (e.g. arrhythmia), chest pain (acute coronary syndrome), SOB (e.g. HF)

Respiratory: dyspnoea, cough (e.g. pneumonia), pleuritic chest pain (e.g. pulmonary embolism)

GI: diarrhoea, vomiting (e.g. dehydration/hypotension)

Genitourinary: oliguria (e.g. dehydration/hypotension)

Neurological: visual symptoms (e.g. pre-syncope), headache (e.g. brain tumour), motor or sensory disturbances (e.g. stroke)

MSK: trauma (e.g. secondary to syncope)

Dermatological: rashes (e.g. meningococcal sepsis)

61
Q

What are some medical conditions relevant to LOC?

A

1) Pre-existing syncopal episodes: clarify the type of syncope, triggers, frequency and date of the last event.

2) Epilepsy: clarify the frequency of episodes, treatment and date of the last event.

3) HTN, hypercholesterolemia, coronary artery disease, arrhythmias: all risk factors for cardiovascular syncope.

4) Parkinson’s disease: associated with autonomic neuropathy causing secondary orthostatic hypotension.

5) Diabetes: associated with autonomic neuropathy which can present with orthostatic hypotension.

6) Recent head trauma: associated with an increased risk of seizures.

7) Pacemaker: often used to treat cardiovascular syncope

62
Q

What are some medications relevant to LOC?

A

1) Hypoglycaemic agents: increased risk of hypoglycaemia and seizures.

2) Antihypertensives: increased risk of hypotension and orthostatic syncope

3) Diuretics

4) TCAs: associated with orthostatic hypotension and seizures.

5) Anticonvulsants: if doses recently changed may precipitate a seizure.

6) Short-acting benzodiazepine

7) COCP: increased risk of PE.

8) Corticosteroids: cessation of corticosteroid therapy may result in adrenal insufficiency and secondary orthostatic hypotension.

63
Q

Important SH areas in LOC history?

A

1) General social context & baseline function & mobility

2) Smoking

3) Alcohol

4) Recreational drugs: can cause seizures and syncope

5) Fluid intake: poor fluid intake are can lead to syncopal episodes (e.g. secondary to hypotension).

6) Occupation: identify high-risk activities

7) Driving

64
Q

What is it important to inform patients with LOC about driving?

A

It is important to advise them not to drive until they have been fully investigated and to inform the DVLA of their current medical issues.

65
Q
A

Yr 4 - OSCE Stations (17 decks)

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