Syncope

1. Syncope Karla Lacayo MD GW Emergency Medicine

2. CASES Elderly female presents to the Emergency Department after having had a witnessed syncopal episode at a restaurant 23 year old female comes in to the ED after having a syncopal episode at work 19 year old male basketball player comes in to the ED after syncopal episode that occurred at the end of practice

3. Syncope What is Syncope? The sudden transient loss of consciousness and postural tone caused by an abrupt decrease in cerebral perfusion with subsequent spontaneous recovery Etiologies range from psychiatric illness to life threatening disease

4. What is near-syncope? Near Syncope occurs when symptoms resolve prior to the loss of consciousness

5. Syncope In Framingham study, overall incidence rate of a first report of syncope was 6.2 per 1000 pt years Incidence rates varied widely depending on age Young men � 2.6 per 1000 pt years Men and Women = 80 had 16.9 and 19.5 episodes per pt years respectively

6. Differential Diagnosis Syncope has a huge differential diagnosis Vascular Cardiac Pulmonary Hypovolemia Metabolic CNS Situational Psychiatric

7. Vascular Causes Aortic dissection AAA Vertebrobasilar insufficiency

8. Cardiac Causes Bradydsyrhythmias (Type II 2� block, 3� block) Tachydysrhythmias (SVT, Vtach, Vfib) MI Pacemaker malfunction Aortic stenosis Atrial Myxoma SSS IHSS Cardiac Tamponade

9. Pulmonary Causes PE Tension PTX

10. Hypovolemia Dehydration Poor intake (elderly, NH patient) Excessive output (diuretics) Acute Blood loss GI Bleed Ectopic Pregnancy

11. Metabolic Hypoglycemia

12. CNS SAH TIA/CVA Vertebrobasilar insufficiency

13. Situational Vasovagal Micturition Post-tussive Carotid Sinus Hypersensitivity

14. Psychiatric GAD Panic Attack Somatization Disorder

15. History How long did it take for complete recovery? If seconds to minutes, most likely a true syncopal episode If it takes = 30-60 minutes, then more likely a post-ictal period

16. How do we figure it out? History is key! What was the patient doing when syncopized? What does the patient remember about the period prior to the syncopal episode? Was there any loss of control of bowel and/or bladder? What was the time to complete recovery?

17. History Presence or absence of prodrome � weakness, light-headedness, diaphoresis, constriction of visual fields or blurring of vision Not present in cardiac or most CNS etiologies Is present in vagal episodes

18. History Environmental stimuli Did micturation precede the episode? Did coughing precede the episode? Did rapid movement of neck precede the episode? Did extreme pain/fear precede the episode? Did the person have palpitations prior to episode?

19. History Is there any family history of sudden death at a young age? What medications is the patient taking? Any new medications or changes in medications? Talk to witnesses/EMS!

20. Syncope vs Seizure Syncope is sometimes confused with seizure because myoclonic jerks are often seen with syncope Differences: Syncope usually has no bladder/bowel incontinence or tongue biting No post-ictal period in Syncope

21. Clues to Etiology Did the episode occur in an otherwise healthy young person during or just after exercise? IHSS Did the episode occur just after the person stood up? Orthostatic hypotension leading to syncope

22. Cardiac Dysrhythmias More common in older individuals No prodrome (except palpitations) Diagnosis: EKG, EPS, Electrolytes

23. Vasovagal Syncope Has prodrome of light-headedness, nausea, warmth, narrowing of visual fields Brief in duration Usually preceded by stressful, anxiety provoking, or painful event Diagnosis: if not obvious, can do tilt table testing

24. Aortic Stenosis Triad of Chest pain, DOE, Syncope in older individual High pitched systolic crescendo-decrescendo murmur at RUSB radiating to neck Diagnosis: Echo

25. AAA Elderly individual with HTN, CAD Low back pain or flank pain occasionally radiating to groin Ruptured AAA: Hypotension, back pain and pulsatile abdominal mass Diagnosis: CT of abdomen with IV contrast

26. IHSS Often seen in young otherwise healthy individuals Often have FH of early sudden death Syncope during/after exercise No prodrome Sudden death during exercise can be first presentation Diagnosis: Echo

27. Ectopic Pregnancy Vaginal bleeding, lower abdominal pain Get urine hCG on every female of reproductive age! If + urine hcg Pelvic U/S Serum Beta-hCG Type and Rh, PT/PTT, CBC

28. CNS Headache, focal neurologic findings Was there a sentinel HA? Dysarthria, dysphagia, diplopia, dizziness?

29. Medications Beta blockers Diuretics Calcium channel blockers Vasodilators (nitrates) ACE-I Anti-arrhythmics

30. Micturation Syncope Most often present in men experiencing nocturia Etiology is vagally mediated decrease in peripheral vascular resistance secondary to a decrease in intrabdominal volume Pts often asymptomatic once get to ED

31. Post-Tussive Syncope Bimodal distribution � young children and older individuals Unremitting coughing episode during which pt becomes weak, light-headed, pale, and diaphoretic Etiology � postulated to be secondary hypocapnia causing increased cerebral vascular resistance and vagally mediated peripheral vasodilation Pts often asymptomatic upon arrival to ED

32. Work-Up Work up is based on history and physical Everyone ? D-stick,CBC, Chem-7 and EKG Female of reproductive age? urine hCG HA ? CT of Head Chest pain? CEs, D-Dimer, CXR or CT of chest DOE ? Echo

33. Dispo Young otherwise healthy individuals who have a good story for vasovagal syncope can be discharged Older individuals � most will need to be admitted for further testing (Echo, EPS, Carotid dopplers) Young individuals with no clear etiology will need to be admitted for observation and w/u (Echo)

34. Dispo Admit if elderly and have co-existing medical conditions High Morbidity and Mortality if = 65 yrs of age Abnormal EKG Syncope without prodrome Hx of CAD Syncope related to exertion

35. Back to the cases�. Elderly female presents to the ED after having had a witnessed syncopal episode at a restaurant What is she at highest risk for? AAA SSS, Tachy/Bradydysrhythmia Aortic stenosis VBI/CVA/TIA

36. Back to the Cases� 23 year old female comes in to the ED after having a syncopal episode at work What is she at highest risk for? IHSS Ectopic pregnancy PE Aortic dissection (Marfan�s)

37. Back to the cases� 19 year old male basketball player comes in to the ED after syncopal episode that occurred at the end of practice What is he at most risk for? IHSS PE Aortic dissection (Marfan�s)