Syncope

Question 1

Categories of Syncope

Answer 1

Neurally mediated/Vaso-Vagal syncope,
Orthostatic Syncope,
Cerebrovascular,
Cardiopulmonary

Question 2

Pathophysiology

Answer 2

Occurs d/t global cerebral hypo-perfusion.
3-5 sec when upright.
15 sec when recumbent.

Question 3

PE for Syncope Eval

Answer 3

1. Vital signs with pulse oximetry
2. Orthostatics
3. Cardiac exam: murmurs, bruits, displaced apex
4. Neuro: exclude focal deficit
5. Careful head/skeletal assessment to exclude fall trauma.

Question 4

Labs/Diagnostics for syncope eval

Answer 4

ECG,
Cardiac monitor,
Urine pregnancy

Question 5

Initial Intervention

Answer 5

IV access,

Crystalloid IV fluids if warrented by fluid status

Question 6

Features of Seizures

Answer 6

Onset unrelated to postural changes or activity,
Preceding aura,
Tonic-clonic movements,
Incontinence,
Post-ictal period/syptoms–>confusion, drowsiness, paresis, myalgias,
LOC often >5 min

Question 7

Pathophysiology of Vaso-vagal syncope

Answer 7

reflex tone causes bradycardia & vasodilation

Question 8

Triggers/History Clues to vaso-vagal syncope

Answer 8

usually standing or sitting;
Pain, cough, micturation, defecation, pregnancy & situational;
Typically Young

Question 9

PE of vaso-vagal syncope

Answer 9

pale, diaphoresis, dilated pupils & bradycardia

Question 10

Disposition for vaso-vagal syncope

Answer 10

Reassurance & DC

Question 11

Pathophysiology of orthostatic syncope

Answer 11

arterial hypotension in upright position

Question 12

Triggers/history clues to orthostatic syncope

Answer 12

Rapid change to upright position;
Preceding light-headedness, weakness or vision change;
GI Blood loss, dehydration, or autonomic dysfunction

Question 13

PE for orthostatic syncope

Answer 13

+symptoms, or HR increase by 30, BP decreased by 20, or SBP <90

Question 14

Dispoition for orthostatic syncope

Answer 14

DC unless uncorrectable with fluids

Question 15

Causes of Cerebro-vascular syncope

Answer 15

Migraine,
Carotid sinus syncope,
Subclavian steal syndrome,
Basilar artery insufficiency

Question 16

carotid sinus syncope

Answer 16

tight collars or strangulation

Question 17

Subclavian steal syndrome

Answer 17

vertigo or angina with left arm movement;

PE clue: unequal BP in arms

Question 18

Basilar artery insufficiency

Answer 18

think of as stroke syndrome;

May have ass. vertigo, diplopia, or ataxia

Question 19

Etiologies of cardiopulmonary syncope

Answer 19

Rhythm Disturbances,
Ventricular outflow obstruction,
Ventricular inflow obstruction,
MI,
Pulmonary vascular dz,
Aortic dissection

Question 20

Clues that suggest cardiopulmonary syncope

Answer 20

recumbent onset (happens while sitting down);
Exertional onset (worry about aortic stenosis);
Palpitations (Vtach is most common);
Personal or family hx of structural or ischemic dz

Question 21

Most common dysrhythmias casing cardiopulmonary syncope

Answer 21

ventricular tachycardia

Question 22

Most common structural cause of cardiopulmonary syncope

Answer 22

Aortic stenosis

Question 23

Aortic Stenosis

Answer 23

exertional syncope with SOB & angina;

Mid-systolic murmur with LV lift

Question 24

Hypertrophic Cardiomyopathy

Answer 24

Exertional syncope with/without chest pain or DOE;
Systolic murmur increases with exertion
S4 heart sound

Question 25

Pulmonary vascular causes of cardiopulmonary syncope

Answer 25

Pulmonary Embolus, | Pulmonary HTN

Question 26

RF predictive of 1 yr mortality following syncope

Answer 26

Abnormal EKG, Hx of dysrhythmias, Age>45, Hx of CHF

Question 27

Young pts (<45) are low risk unless:

Answer 27

Exertional syncope, | Family hx of sudden death

Question 28

ACEP Syncope admission Recommendations

Answer 28

``` Abnormal EKG, Age >45, Established CAD, Ventricular dysrhythmias, Structural heart disease, CHF, Hematocrit < 30%, Suspicion of life threatening disease ```