syncope2 Flashcards Preview

CSI > syncope2 > Flashcards

Flashcards in syncope2 Deck (37):
1

what is syncope?

The abrupt and transient loss of consciousness associated with absence of postural tone, followed by complete and usually rapid spontaneous recovery

A symptom and NOT a diagnosis

2

impact

30% of adult population will experience syncopal episode

3% of all ED visits in US

Can lead to significant morbidity

50% of the time a specific cause is NOT identified during initial evaluation

3

Important to distinguish Syncope from other causes of LOC:

Pre-Syncope: lightheadedness without LOC

Drop Attack: loss of posture without LOC

Seizure: Tonic-Clonic Movements that start WITH LOC (vs hypoxic myoclonus which can occur with syncope), post-ictal recovery period

hypoglycemia
hypoxia

4

types of syncope

Vasodepressor
AKA (Vasovagal/Neurocardiogenic)
*Most Common*

Cardiovascular (most dangerous)

Orthostatic Hypotension

Neuro / Functional / Psychiatric -

5

Vasodepressor
AKA (Vasovagal/Neurocardiogenic)
Most Common

decrease preload-->not enough blood to brain for short amount of time, comes back

Pain/Noxious Stimuli
Situational (micturation (oldies), cough, defecation)
Carotid Sinus Hypersensitivity (CSH)
Fear (inc. vagal tone)
Prolonged heat exposure

Arrhythmia – Tachycardia/Bradycardia
Mechanical – Aortic Stenosis, HOCM

6

Orthostatic Hypotension

Drugs: BP meds - Vasodilators, Diuretics, Alpha blockers

Autonomic Insufficiency (Parkinsons, DM, Adrenal Insufficiency)

Hypovolemia: Dehydration, Blood loss, infection

7

Neuro / Functional / Psychiatric -

Pseudosyncope
TIA or Vertebrobasilar Insufficiency

8

most important thing in syncope..

hx is absolute key!!

9

more vasodepressor syncope:

Due to excessive vagal tone
Vasovagal Hypotension: Initiated but stressful, painful situation

Situational Vasovagal Syncope: Associated with activity that may cause increase in vagal tone
-Micturation Syncope
-After Defecation
-Post Prandial




10

more vasodepressor syncope: Carotid Sinus Hypersensitivity: (Common in Elderly)

-Sensitive Baroreceptors in Carotid body – when activated can decrease HR and drop BP = possible Syncope
-May occur with pressure on neck – tight collar, turning neck

-if massage carotid body, it "goes haywire" causing dec. HR and BP
10 second pause of sudden cardiac death!

11

orthostatic syncope

*one of the most common presentations in hospital*

Common in Elderly
Essentially Pooling of blood in LE – while standing or sitting up – leading to decreased Preload = Syncope

12

causes of orthostatic syncope

Autonomic Insufficiency : ex: DM Neuropathy (not able to "squeeze down as fast")

Hypovolemia:
- Dehydration (Decreased thirst/ infections)
- Blood loss

Medications:
- Vasodilators (i.e. hydralizine)
- Alpha Blockers (flomax, tamsulosin)
- Diuretics

13

Orthostatic BP Measurement:

Measure same arm
Measure while patient laying, sitting and standing
Wait 5min between change of position

POSITIVE IF:
a drop in BP of >= 20 mmHg
or in diastolic BP of >=10 mmHg
or experiencing lightheadedness or dizziness

14

Cardiogenic Syncope

Mechanical or Arrhythmic

not able to maintain CO

15

Cardiogenic Syncope: mechanical problem

Valvular: ("less lanes of traffic")
Aortic Stenosis
Pulmonic Stenosis (less common)

Structural:
HOCM
Severe Cardiomyopathy (i.e. DCM, EF 15!)
Myxoma (intracardiac tumor on septal wall obstructing mitral valve)

16

Cardiogenic Syncope: arrhythmias

Tachycardia:
SVT
VT
VF

Bradycardia:
Sinus Brady
AV blocks
AV dissociation

17

Aortic stenosis (mechanical cardiogenic syncope)

LV outflow tract gradient secondary to stenosis of Aortic Valve
Aortic Stenosis likely secondary to senile degeneration/ bicuspid aortic valve

CO= SV x HR

normal pressure gradient:
LV: 120/10, Aorta: 120/80, LA: 10

aortic stenosis pressure gradients:
LV: 200/25, Aorta 110/75, LA: 25

2 year mortality: 50%

*Syncope as presenting symptom Aortic Stenosis indicates Poor Prognosis: fix with sx: replace valve

18

FA: Aortic stenosis

Crescendo-decrescendo S1S2 systolic ejection murmur.

LV >> aortic pressure during systole. Loudest at heart base; radiates to carotids. “Pulsus parvus et tardus”—pulses are weak with a delayed peak. Can lead to

*Syncope, Angina, and Dyspnea on exertion (SAD).
Often due to age-related calcification or early-onset calcification of bicuspid aortic valve

19

Hypertrophic Obstructive Cardiomyopathy

??

20

severe sinus bradycardia EKG:

around 20!

21

high grade 2nd degree AVB EKG:

dropping every other QRS complex
regular P waves

"high grade": could be mobitz 1 or 2

22

Third degree AVB EKG:

A-V dissociation ("marching at own beats")
needs pacer

23

SA/AV nodal dysfunction with Pauses EKG:

almost 9 second pauses!!
needs pacer

24

arrythmias: bradycardia: consider different part of equation

CO=HRxSV
here the HR is low causing the decrease CO

25

tachycardias

CO=HRxSV
with inc. HR-->EDV decreases due to dec. filling time-->dec. SV-->dec. CO-->syncope

26

SVT EKG

narrow complex QRS

if ventricular rhythms: would have wide QRS, SUPRAventricular has narrow QRS

HR above 150, hard to tell what type of SVT, give meds to slow down to see rhythm better
@ 180 may pass out

27

Vtach EKG, what to do?

shock 'em

28

Vfib

nonperfusable rhythm, shock them

29

syncope dx

HISTORY IS KEY !!!!!!!!!!
obtain vitals
review meds
initial EKG
do othostatics
stress test

further cardiology testing if negative tests, suspicion for arrhythmias:
holter monitor
event monitor

carotid sinus massage
tilt table testing: to evaluate for vasodepressor syncope

30

syncope dx: vasodepressor

-Usually Associated with premonitory symptoms – Nausea, Diaphoresis
- Ask for activity pt was doing at the time

31

syncope dx: orthostatic

-Ask if occurred while patient was attempting to sit up or stand

32

syncope dx: cardiogenic

-Ask for palpitations, SOB, any prior episodes

33

dx testing is driven by

clinical suspicion based on History

34

vasodepressor syncope tx

Avoid situations that may cause symptoms
(i.e. sit down when urinating at night)

35

orthostatic syncope tx

Avoid dehydration
Encourage oral hydration
Volume expanders – Fludricortisone
Vasoconstrictor – Midodrine

36

cardiogenic syncope tx

bradycardia:
Adjust medications (i.e. decrease B-blocker)
Evaluate for Pacemaker placement

tachycardia:
B-blocker or CCB
EP study or ablation if needed

Mechanical:
Treatment for AS or HOCM

37

cardiovascular syncope

Arrhythmia – Tachycardia/Bradycardia
Mechanical – Aortic Stenosis, HOCM