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SWOONING AND VAPORS

SWOONING AND VAPORS. Syncope and near syncope. Syncope accounts for 3% ER visits. Syncope/pre-syncope symptoms are due to a reduction in cerebral perfusion, most often as result of decreased blood pressure. Blood pressure is dependent on. Cardiac output Vascular tone Vascular volume.

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SWOONING AND VAPORS

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  1. SWOONING AND VAPORS Syncope and near syncope

  2. Syncope accounts for 3% ER visits • Syncope/pre-syncope symptoms are due to a reduction in cerebral perfusion, most often as result of decreased blood pressure.

  3. Blood pressure is dependent on • Cardiac output • Vascular tone • Vascular volume

  4. Cardiac output • HEART RATE: too slow/fast, arrhythmias • MECHANICAL: aortic/mitral stenosis; pulmonary emboli; HOCUM; Cardiomyopathy

  5. VASCULAR VOLUME • Blood loss • dehydration

  6. VASCULAR TONE • Drugs • Neuromediated • Autonomic insuffiency • Orthostasis • Vascular disease-carotid, vertebralbasilar

  7. CAUSES OF SYNCOPE • Cardiac: 14% arrhythmia/ 4% mechanical • Neurologic: 10% • Neurally mediated: Vasovagal 18-25% • Orthostatic: 8-10% • Psychiatric: 2% • No clear etiology 33-45%

  8. PROGNOSIS VARIES WITH ETIOLOGY • Cardiac syncope Non-cardiac syncope • 25% 1 year mortality -7% 1 year mortality • 14% 1 year CSD -3% 1 year CSD

  9. HISTORY AND PHYSICAL • More than 50% of diagnosis should come from History and Physical

  10. Prior incidence? • Behavior at time of event • Symptoms prodrome? • Duration of LOC? • Mental status afterwards • Witness information?

  11. BEHAVIOR/CONDITIONS Postural change Cough Swallowing Head turning/neck pressure Defecation Pain Strong emotion Prolonged standing At rest or with activity Tremor seizure activity

  12. Symptoms • Nausea • Pallor • Warmth/flushed • Diaphoresis • Palpitations • Visual/hearing changes • Confusion • headache

  13. Duration of LOC/event seconds-hours • Mental status after postictal/washed out • Witness information

  14. Past medical History • Structural heart disease • Previous heart rhythm problems • Seizure history • Vascular disease • Drugs and recent changes

  15. PHYSICAL EXAM • Vital signs, including orthostatic blood pressures->20 mmHg drop in BP with standing • Carotid hypersensitivity>3 sec pause, 50 mmHg asymptomatic or 30 mmHg symptomatic BP drop (up to 5 sec massage) • Bruits • Murmur • Neurological findings

  16. diagnostics • ECG 5% unselected diagnostic yield • Long QT; afib/flutter; MAT; paced; VPB; V tach; bundle branch block; LVH; Old MI;WPW; Mobitiz type II • ECHO: 5-10 %unselected diagnostic yield • EST: activity associated symptoms • Monitor holter/event monitor • Tilt table test

  17. NEUROCARDIOGENIC SYNCOPE • Very common 20-25% in most series • Usually manifests by second decade of life • Abnormal reflex-mediated • Usually upright position • Trigger/prodrome • Decreased venous return; increased LV contractility; mechanical receptor activation—leads to—vasodilatation/bradycardia—manifests as hypotension-syncope

  18. SYCOPE DIAGNOSIS SCORING SYSTEM • PATIENT FEATURE POINTS • Female, <42 yrs 7 • Syncope/presyncope • Headache/flushing/pain 3 for each • Nausea 2 • Diaphoresis 2 • Male <43 yrs 2 • Prolonged orthostasis 1 • Cyanosis -4 • Diabetes -4 • Bifasicular block -3 • Chest pain with fainting -2 • Postictal confusion -1 • Memory of fainting -1 • Score 3 or > vasovagal syncope; score 2 or less another source

  19. NEUROCARDIOGENIC SYNCOPE • Triggers: pain; strong emotion/stress; prolonged standing • Situational: micturation; defication; cough; deglutation

  20. PREDICTORS OF POOR OUTCOME IN SYNCOPE PATIENTS • Abnormal ECG-non-specific ST or sinus tachycardia • Prior ventricular arrhythmia >10VPB/hr; VPB pairs; multifocal VPB • CHF history • Age >45 years (without prior history of syncope) • If 0 5% 1year arrhythmia/death • If 1 10% • If 3-4 60%

  21. WHEN TO HOSPITALIZE • History of chest pain • Hx of CAD, CHF, Ventricular ectopy • Evidence of CHF,AS, focal neuro defect • ECG abnl.-BBB; ischemia; MI;arrhythmia • Consider-for exertional syncope; frequent spells; age >70 yr; orthostasis; sustained physical injury; suspected ACS

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