Syncope

Question 1

A 78 year old lady presents to ED with a syncopal episode. It was witnessed. She had a very brief loss of consciousness and she did not suffer a head injury. How will you assess this patient?

Answer 1

Impression
Syncopal episode of unknown aetiology. Want to consider a broad range of differentials which may be in cause of this presentation

• Neurogenic: vasovagal episode (micturition, etc); autonomic neuropathy (DM, parkinsons), hypoglycaemia
• Cardiogenic: arrhythmia, valvular disease, carotid stenosis, ACS
• BP: Postural hypotension (old age), hypovolaemia, medications/drugs

Other DDx

• Stroke/TIA: SAH, ICH, ischaemic
• Vertigo
• Seizure: electrolytes, SOL, drugs, infective, etc
• Migraine
• Mechanical fall
• systemic infection, sepsis

Goals

• Determine likely aetiology of LOC and fall with thorough Hx/Ex/Ix, rule out associated injuries
• investigate thoroughly to rule out red flag DDs

Question 2

Syncope - History

Answer 2

History

• Collateral: before, during (any evidence of seizure), after. how long LOC? post-ictal period?
• sx: light-headedness vs world spinning, pain? acute onset or gradual? happened before?
• RISKS: CVD risk factors, BP medications, other antiarrhythmics, compliance with medications?
• PMHx: parkinsons, diabetes, other autoimmune disease
• psychosocial: driving still?
• SNAP

Question 3

Syncope - Examination

Answer 3

Examination

• General appearance + vitals
• secondary survey for other injuries sustained
• Cardiac: Murmus, BP, PR, postural BPs
• Neuro: focal neurology, post-ictal, GCS, gait assessment
• Parkinsons exam: Gait, Tone, Bradykinesia, Tremor
• Hydration status assessment:
• HINTS/Dix-Hallpike if indicated on Hx findings

Question 4

Syncope - Investigations

Answer 4

Investigations
Lots of DDs are based on clinical diagnosis;
- Bedside: postural BPs, UA, ECG for cardiac arrhythmias
- Bloods: FBC, UEC, LFT, CRP/ESR, troponnis, BNP
- Imaging: MRI Brain, ECHO for structural heart disease, carotid dopplers

Question 5

Syncope - Management (not asked in question)

Answer 5

Managemet
- depends on underlying cause

Overarching mx principles

• falls risk management
• ACAT referral for home assessment
• GP follow-up, DAME risk factors modification with allied health involvement for MDT
• medications review - esp BP lowering meds