Syncope

Question 1

What is difference between loss of consciousness and syncope

Answer 1

Loss of consciousness can be divided into syncopal and non syncopal causes
Syncope refers to cutting of perfusion between heart and brain

Question 2

What can syncope be classified into

Answer 2

Cardiac
Reflex
Orthostatic
Cerebrovascular

Question 3

What happens in reflex syncope

Answer 3

Believed to be due to primitive reflex to play dead where in scary situation BP and HR temporarily

Question 4

What are cerebrovascular causes of syncope

Answer 4

Non cardiac structural causes of loss of brain perfusion
Aortic dissection
Subclavian steal syndrome
Vertebrobasilar insuffiency
TIA

Question 5

What causes orthostatic syncope

Answer 5

When stand there is sudden drop in BP that compensate for by vasoconstriction particularly the veins in the leg

Question 6

What are reflex causes of syncope

Answer 6

Vasovagal
Carotid sinus hypersensitivity
Situational syncope

Question 7

What causes straining syncope

Answer 7

For example in peeing and pooing your BP doesnt adapt in time

Question 8

Cardiac causes of syncope

Answer 8

Arrythmias
Aortic stenosis
HCM
HB
PE

Question 9

What causes orthostatic syncope

Answer 9

Drugs- anti-sympathetics, anti-hypertensives
Dehydration
Autonomic instability
Baroreceptor dysfunction

Question 10

Who does baroreceptor dysfunction occur in

Answer 10

HTN- fail to accurately control BP

Question 11

What is described before a vasovagal episode

Answer 11

Odd sensation in stomach
Pallor
Sweaty
Nausea
Knowing going to fall

Question 12

What does syncope while playing sport/exercising suggest

Answer 12

HOCM
Aortic stenosis
Long QT

Question 13

What does just sitting down or watching tele before syncope suggest

Answer 13

Arrythmia

Question 14

Most common cause of syncope in the elderly

Answer 14

Orthostatic due to medications

Question 15

What medications can cause syncope and how

Answer 15

Diuretics- fluid loss
ACEi- fluid loss and vasodilation
Beta blockers- failure to increase HR and BP on standing
A blockers- inability to constrict vessels in legs
CCB- inability to vasoconstrict and some affect heart

Question 16

What is main concern of syncope in the elderly

Answer 16

Leads to morbidity- broken bones, loss of confidence, loss of independance etc
Leads to mortality- bleeds in brain, VTE and infections from prolonged bed rest
Cost of adapting house to new circumstances or affording to go into nursing home

Question 17

What does syncope with no warning suggest

Answer 17

Cardiac

Cerebrovascular ie subclavian steal

Question 18

Important questions to ask about before syncope

Answer 18

Warning Sx?
What doing at the time?
Head injury recently?

Question 19

What is significant about recent head injury in syncope

Answer 19

Subdural bleed

Question 20

Causes of non-syncopal blackout

Answer 20

Intoxication
Head trauma
Metabolic-hypoglycaemic, HHS, DKA
Epileptic seizure
Psycogenic seizure
Narcolepsy

Question 21

History of IHD in syncope

Answer 21

Ischaemia- HB, arrythmia

Medications- orthostatic

Question 22

How long do arrythmia syncopes last

Answer 22

Seconds

Question 23

What to ask about for during seizure

Answer 23

Tongue biting- epilepsy

Twitching and incontinence- not necessarily can also be arrythmia and vasovagal

Question 24

Questions to ask about after syncope

Answer 24

Confused or weakness- seizure

How long to recover and how?

Question 25

Syncope that lasted minutes

Answer 25

Seizure

Question 26

Continuous similar episodes of syncope

Answer 26

Epilepsy

Question 27

Syncope followed by weakness in arm

Answer 27

Todds paresis | TIA

Question 28

How can diabetes lead to syncope

Answer 28

Polyuria-> orthostatic Vascular disease predisposed Autonomic dysfunction Hypoglycaemia

Question 29

How is psyciatric illness relevant to syncope

Answer 29

Predisposes to non-epileptic seizures

Question 30

Significance of drug history syncope

Answer 30

``` Insulin and T2DM hypoglycaemics Antihypertensives Vasodilators Antiarrythmics Antidepressants Warfarin ```

Question 31

Why are antiarrythmics significant in syncope history

Answer 31

Paradoxically predispose to arrythmias

Question 32

Why are antidepressants significant in syncope history

Answer 32

TCAs cause hypotension

Question 33

Why is warfarin or DOACs significant in syncope history

Answer 33

Increase likelihood of subdural bleed following trauma

Question 34

Significance of recreational drugs in syncope

Answer 34

Coacaine arrthymias

Question 35

Significance of alcohol in syncope history

Answer 35

Subdural predisposition | LOC leading to bleed

Question 36

Importance of family history syncope

Answer 36

Sudden death in under 65 may have been caused by Long QT, WPWS and HOCM

Question 37

What to look for in examination of syncope

Answer 37

``` Tongue bitten- epilepsy Pulse and obs- heart problems Dehydration status- orthostatic Heart murmur- HCM or aortic stenosis Focal neurology signs- ICP from bleed or tumour causing seizure ```

Question 38

Investigations for syncope

Answer 38

``` Bloods- glucose, U&Es, FBC ECG Holter potentially CT/MRI if epilepsy indicated Echo if heart implied ```

Question 39

Why do FBC syncope

Answer 39

Anaemia can be contributing factor

Question 40

Why do glucose syncope

Answer 40

DM predisposes to cardiac problems and hypos

Question 41

Why do U&Es

Answer 41

Urea in absence of creatinine is dehydration | Electrolyte imbalance predisposing to long QT

Question 42

Why is history of mental health significant in blackout

Answer 42

TCAs cause hypotension | Predisposed to non epileptic

Question 43

What does history of non stereotyped and inconsistent blackout stories suggest

Answer 43

Non epileptic seizures

Question 44

History of BPH in syncope

Answer 44

On alpha blockers causing impaired vasoconstriction

Question 45

What is stokes adams attack

Answer 45

When LOC due to complete HB

Question 46

What happens if stokes adams attack occurs for more than 15 seconds

Answer 46

Twitching due to brain anoxia

Question 47

What happens after a stokes adams attack

Answer 47

Facial flushing as flow returned to face

Question 48

How can partial seizures be classsified by lobe based on sx

Answer 48

Frontal- motor Parietal- sensory Occipital- visual problem Temporal- deja vu, smells/sounds aura

Question 49

Which heart block is common in fit younger people

Answer 49

Mobitz T1

Question 50

What can be investigation for vasovagal syncope

Answer 50

Tilt table test

Question 51

What happens in tilt table test

Answer 51

Patient laid supine and moved about- posiive test if experience LOC with drop in HR and BP or they experience some symptoms related to vasovagal episodes

Question 52

What is the main problem with anticonvulsant medications

Answer 52

Theyre teratogenic

Question 53

Syncope brought on by using arm for a long time

Answer 53

Subclavian steal syndrome

Question 54

Syncope brought on when putting tie on

Answer 54

Carotid sinus hypersensitivity

Question 55

What is carotid sinus hypersensitivity

Answer 55

When the carotid sinus exaggerates response to pressure on it

Question 56

What is test for carotid sinus hypersensitivity

Answer 56

Carotid sinus massage while attached to cardiac monitor with IV cannula in place in case go into cardiac arrest instead of syncope

Question 57

What is brugada syndrome

Answer 57

Autosomal dominant condition with mutation in calcium sodium channel gene leading to RBBB and ST elevation in V1-V3 predisposing to ventricular dysrythmias

Question 58

ECG changes in brugada syndrome

Answer 58

RBBB and ST elevation in V1-V3

Question 59

How to tell from lying vs standing BP if cause is hypovolaemic or autonomic dysfunction

Answer 59

In hypovolaemia will be associated tachycardia whereas in autonomic dysfunction will be the same