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Flashcards in Syncope Deck (38)
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1

What is syncope

sudden transient LOC and postural tone with spontaneous recovery
self limited, rapid onset
spontaneous complete recovery without intervention

2

What are some pre-syncopal symptoms

extreme light-headed/dizzy
Tunnel vision
Graying out
Altered consciousness
Palpitations
Generalized weakness
Tremulousness

3

What are the causes of TRUE syncope

Neurally mediated (vasovagal, situational, carotid sinus syndrome)
Orthostatic (drug induced, ANS failure)
**Cardiac arrhythmia (brady, tachy, long QT syndrome)
Structural cardio-pulmonary

4

What are some differentials for true syncope

**Somatization disorder (pseudo-syncope)
Seizure
Sleep disorder
Trauma/concussion
Hypoglycemia
Hyperventilation
POTS

5

What are key points to inquire about on history s/p syncopal episode

Get as many details about event (witnessed? what happened during? change in position exertion? CP? prior episodes?)
Distinguish form possible seizure
H/o cardiac disease? CVA/TIA? diabetes?
Fix of CAD? sudden death? syncope? seizures? arrhythmias?
--Cyanosis? tonic clonic? urine incontinent? tongue biting? post-octal confusion? duration?

6

What meds are important to inquire about

anti-HTN/depressive/anginals
analgesica/narcotics
muscle relaxers
anti-arrhythmatics
anti-ED
alcohol
recreational drugs

7

What can occur during the prodrome of a syncopal episode

uneasiness/apprehension
visual blurring
CP/SOB (cardiac syncope)
HA/focal neuro Sx
Vasovagal (light headed, facial pallor, diaphoresis, nausea)

8

What should you assess for on physical exam s/p syncope

pallor vs cyanosis
orthostasis (+ if 20+ drop in SBP or 10+ drop DBP 3 minutes after supine to standing)
abn rhythm, murmur, PMI, carotid brutis
MSE (assess LOC)
pupils, EOM, facial symmetry, tongue midline
imbalance/incoordination (cerebellar dysfunction)

9

What diagnostic studies would be good to get for syncopal suspicion

CBC, CMP, trop
ECG (holter monitor?)
Echo (if with risk factors)
Additional workup if CV abnormality or arrhythmia suspected (Echo, Holter, external loop recorder, external patch, mobile telemetry, ICD)

10

What extensive diagnostic tests are available depending on H&P

EP study
carotid UD
stress test
cardiac imaging
neuro test (MRI/EEG)
Tilt table test

11

When is a Tilt table test indicated

if recurrent episodes of unexplained syncope occur
Tests for vasovagal syncope
Can help patient recognize prodromal symptoms

12

How do you preform a tilt table test

Lie patient down, then tilt patient upright 60-90 degrees
Abn: exaggerated drop in BP w or w/o drop in HR, associated with dizziness and light headed

13

What if there is a focal deficit on exam/ Normal exam

Deficit: CT +/- MRI brain, consider angio
If neuro exam is normal but neuro component suggested, refer for autonomic testing

14

What is vasovagal syncope

common faint, most common cause of syncope
short duration, fatigue
more common in younger patients and females
solitary attacks, no Rx needed

15

What are triggers for vasovagal syncope

heat exposure, prolonged standing, physical exertion

16

What are classic prodromal symptoms of vasovagal syncope

light headed, diaphoresis, palpitations, nausea, visual blurring/tunnel vision, diminution of hearing, pallor

17

What are triggers in situational syncope

micturition, cough, defecation, swallowing, emotional state, painful stimuli

18

What is the treatment for vasovagal syncope

avoid triggers!
education (counter pressure maneuvers, like tilt training)
If suspected ANS dysfunction, liberalize salt and water intake, compression stockings
May consider pacing

19

What is carotid sinus syndrome

syncope associated with carotid sinus stimulation (shaving, tight neck collar, prior head/neck surgery)
Characterized by drop in BP 50+ mmHg, or sinus pause >3 seconds
Usually older patients, VERY rare

20

how can you diagnose CSS

carotid massage can reproduce syncope (don't do if with carotid bruit, prior TIA, stroke, or MI w/in 3 months)

21

How do you treat CSS

avoid triggers, consider pacing

22

What do 2017 guidelines recommend for assessing orthostatic hypotension

assess 3 minutes after standing
BUT, JAMA 2017 says 1 minute most clinically relevant

23

What are causes of orthostatic syncope

Hypovolemia
Meds (CCB, diuretics, vasodilators, BB)
ANS dysfunction (lesions on peripheral nerves AKA MS/parkinsons) (secondary ANS failure d/t DM, alcohol, amyloid)

24

How do you treat orthostatic syncope

If d/t dehydration, give fluids
If drug related, stop drug
If neurogenic, compression stocking/ Midodrine, Droxidopa, Fludrocortisone
Physical counter pressure maneuvers
Tilt training
Water intake (peak intake at 30 min)/ liberal salt intake (6-9g/d)

25

What should you do if orthostatic syncope continues to recur

consider pharm intervention with Midodrine or Fludrocortisone

26

What is cardiac arrhythmia syncope due to

Afib
SVT
Vtach
high degree AV block
Brugada

27

What does cardiac syncope yield

LOWER survival than other syncopes

28

What are bradyarrhythmias due to

Sick Sinus Syndrome (SA node dysfunction causes intermittent pause with tachy-brady syndrome)
AV block (Moritz II, Complete heart block)

29

What are tachyarrhythmias due to

SVT
WPW
Afib/flutter with RVR
V-Tach
V-Fib
Torsades (QT prolonging drugs; anti-emetics like zofran and compazine)

30

What are some QT prolonging drug classes

antiarrhythmics
antimicrobials
antidepressants
antipsychotics
Arsenic/Methodone