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Syncope Presentation
- 1. Syncope Dr. Boney Cheriyan Thavalathil Emergency Physician and Intensivist
- 2. Definition • “Transient self limited loss of consciousness with an inability to maintain postural tone that is followed by spontaneous recovery” • Excludes coma, seizures, shock & other states of altered consciousness
- 3. Baroreceptor anatomy • Baroreceptor location = heart, vena cavae, carotid sinus(CN IX), aortic arch(CN X) • Baroreceptor impulses NTS excitatory fibres to caudal ventrolateral medulla inhibitory fibres to rostral ventrolateral medulla which sends excitatory fibres to syampathetic preganglionic neurons
- 4. Baroreceptor activation • Stretch sensitive mechanoreceptors
- 5. What is Bezold Jarisch reflex?
- 6. Morbidity/ Mortality • Cardiac syncope = poor outcome • Morbidity from syncope ▫ Recurrent syncope ▫ Lacerations ▫ Extremity # ▫ Head injuries ▫ Motor vehicle accidents
- 7. Risk Stratification • San Francisco Syncope Rule ▫ At the time of triage: systolic <90 mmHg ▫ Patient complaint of a SOB ▫ History of CHF ▫ Hematocrit <30 ▫ ECG Does the patient have a rhythm that is not sinus? Does the patient have new changes on their ECG?
- 8. San Francisco Syncope Rule • C: CHF history • H: Hematocrit < 30 • E: ECG changes • S: Systolic <90 • S: Short of Breath
- 9. San Francisco Syncope Rule Results • A study from June 00-Feb 02 (J of EM Oct 2005) comparing the application of this rule vs physician judgment in predicting which patients will have a serious outcome within 7 days of the ED visit • Both physicians and the SFSR were able to predict those who will have a serious outcome • BUT, physicians still admitted many patients even though they felt they were low risk • If the SFSR had been utilized, there could have been a 10% decrease in admission of the low risk group
- 10. ROSE criteria • Prediction of serious outcome within 30 d ▫ Elevated BNP ▫ Hemoccult +ve stool ▫ Presence of Q waves in ECG ▫ Low O2 saturation • 87 % sensitivity & 98.5% negative predictive value
- 11. Age • Syncope occurs in all age groups but is most common in adults • Young adults non cardiac causes more common • Advancing age cardiac causes predominate • Pediatric syncope UNCOMMON Therefore warrants prompt detailed evaluation
- 12. Causes of syncope • Vascular ▫ Neurocardiogenic ▫ Postural ▫ Post prandial ▫ Micturition ▫ Carotid sinus syncope
- 13. Causes of syncope • Obstructive ▫ Aortic sinus ▫ HOCM ▫ Pulmonary stenosis ▫ Fallot’s tetralogy ▫ Pulmonary HTN/ embolism ▫ Atrial myxoma ▫ Defective prosthetic valve
- 14. Causes of syncope • Arrythmias ▫ Rapid tachycardia ▫ Profound bradycardia (Stokes Adam syndrome) ▫ Significant pauses ▫ Artificial pacemaker failure ▫ Ventricular arrythmias
- 15. Risk factors for serious cause of syncope 1. Exertion preceding the event 2. H/O cardiac disease in the patient 3. Family H/O sudden death, deafness or cardiac disease 4. Recurrent episode 5. Recumbent episode 6. Associated chest pain/ palpitations 7. Prolonged loss of consciousness
- 16. Situational syncope?? • Syncope occurring with a fixed event • Examples include micturition; deglutition; exercise induced and carotid sinus syncope. • Stimuli autonomic reflexes with a vasodepressor response transient cerebral hypotension SYNCOPE
- 17. Prehospital Care• Rapid assessment of airway, breathing, circulation & neurological status • May require ▫ O2 administration ▫ Advanced airway techniques ▫ Intravenous access ▫ Glucose administration ▫ Pharmacological circulatory supports ▫ Defibrillation or temporary pacing
- 18. Evaluation of Syncope Patient in ED • Rapid Assessment: If patient unstable, support ABC’s and other necessary means of stabilisation BUT… • Also important to talk to family members or other individuals at the scene
- 19. History • Should include the following points ▫ Abrupt or gradual onset If it is abrupt while sitting or supine, suspect cardiac etiology Was LOC of rapid onset & short duration Was there complete spontaneous recovery without sequelae? Was postural tone lost? ▫ Events prior to syncopal episode
- 20. History • Associated with exertion?? Possible outflow obstruction • Hot environment?? Orthostasis • Associated with CP/ SOB ?? Possible MI, dissection, PE • Headache?? Possible intracranial haemorrhage • Abdominal pain?? r/o dissection, ruptured aneurysm, ectopic pregnancy • Diaphoresis/ dizziness Vasovagal
- 21. History • What happened during the event and how long did it last? ▫ Tonic-clonic movements? Possible seizures ▫ Trauma from fall or did they pass out before they fell?
- 22. History • Pertinent past medical history ▫ H/O seizure disorder ▫ CAD ▫ CHF ▫ Aneurysms ▫ Aortic stenosis ▫ GI bleed ▫ Diabetes ▫ HTN
- 23. Medications • Remember to get a full medication list and ask about… ▫ Changes in meds ▫ Compliance with medications ▫ Eating after medications (i.e. Insulin)
- 24. Drugs implicated in syncope • Agents that reduce B.P?? (Antihypertensive drugs, diuretics, nitrates) • Agents affecting C.O (beta-blockers, digitalis) • Agents that prolong the QT interval?? (TCA, phenothiazines, quinidine, amiodarone) • Agents that alter sensorium? (alcohol, cocaine, sedative analgesics) • Agents that alter serum electrolytes?? ( especially diuretics)
- 25. Physical Exam System Pivotal Finding Significance Vital signs Pulse rate/rhythm RR and depth Blood Pressure Temperature Arrhythmias Tachypnea suggests hypoxia, hyperventilation or PE Underlying shock may be present and may contribute to syncope in 15-30% pts. Fever from sepsis may cause orthostasis Skin Color, diaphoresis Signs of decreased organ perfusion
- 26. Physical Exam System Pivotal Finding Significance HEENT Tenderness/defor m. Papilledema Breath Signs of trauma Increased ICP Ketones for DKA Neck Bruits JVD Source of cerebral emboli Right heart failure from ischemia, tamponade or PE Lungs Breath sounds, crackles, wheezes Infection, left heart failure from ischemia, PE
- 27. System Pivotal Finding Significance Heart Systolic Murmur Rub Aortic stenosis, HCM Pericarditis, tamponade Abdomen Pulsatile mass AAA Rectum Hematest stool Anemia, hypovolemia Pelvis Uterine bleeding, adnexal tenderness Anemia, ectopic, hypovolemia Extremities Pulse equality in upper extremities Subclavian steal, aortic dissection Neurologic Mental status, focal deficits Seizure, stroke, other primary neurologic disease
- 28. Diagnostic Studies: What to look for… • 12 lead ECG ▫ Dysrhythmias, ischemia ▫ Normal ECG = “good” prognostic sign • Orthostatics ▫ Orthostatic hypotension • CBC/Electrolytes, Glucose ▫ Anemia, metabolic abnormalities, hypoglycemia • B-HCG ▫ Pregnancy ? Normal intrauterine pregnancy vs ectopic
- 29. Diagnostic Studies: What to look for… • Drug screen and therapeutic drug levels • ABG ▫ Hypoxemia, hyperventilation • CXR ▫ Pneumothorax, dissection • Head CT ▫ Check if new-onset seizure, history of trauma
- 30. Diagnostic studies: Ultrasound • Ultrasound can quickly help identify multiple causes. ▫ Abdominal Abdominal aortic aneurysm/dissection, intraabdominal hemorrhage ▫ Pelvic Ectopic vs. IUP ▫ Cardiac Tamponade, outflow obstruction
- 31. Others• Holter monitor/ loop event recorder To rule out hidden arrythmias • Head-up tilt-table test Procedure with interpretation of results Less sensitive than EPS • EEG If seizure is likely alternative diagnosis • Stress test/ Electro-Physiological Stress (EPS) Mandatory for any patient with suspected arrythmia as cause of syncope
- 32. Others • Carotid massage • Hyperventilation maneuvre • Neurological testing
- 33. How do you differentiate between syncope and pre- syncope??
- 34. Differentials • Adrenal insufficiency & crisis • Drug toxicity eg:- amphetamine, antidepressant, antidysrrhythmic, beta blocker, CCB • Abdominal aneurysm • WPW syndrome • Aortic stenosis • Pulmonary embolism • Long QT syndrome • Hyponatremia • Mitral stenosis • Hypoglycemia • MI • Heart blocks • SAH • Aortic dissection • Tetralogy of Fallot • Brugada syndrome
- 35. Distinguishing characteristics Syncope Seizure • Onset while standing • No history of convulsions • Patient usually has pale and cold extremities • Recovery is usually immediate • Onset can be while patient is supine • Convulsions occur immediately with loss of consciousness • Extremities may be warm, flushed or cyanotic • Prolonged recovery phase
- 36. Pathophysiology of vasovagal syncope Prolonged standing/ stress/ strong emotion Peripheral vasodilatation/ venous blood pooling Decreased blood returned to the heart Stimulates mechanical receptors in the infero-posterior heart wall Heart contracts vigorously Increased ventricular stretch causing vasodilatation & profound bradycardia Decreased B.P and SYNCOPE Reflex via CNS
- 37. What happens in postprandial syncope...? • Main cause:- pooling of blood in the splanchnic vessels after meal • Normally , homeostatic response via activation of baroreceptors & the sympathetic system, peripheral vasoconstriction & increase cardiac output
- 38. How does carotid sinus syncope occur…? Carotid sinus stimulation Exaggerated vagal response Bradycardia & vasodilatation SYNCOPE
- 39. What is orthostatic intolerence?? • Defined as “development of symptoms during upright standing which is relieved by recumbency” • May be due to ▫ Dysautonomia ▫ Compensatory dysfunction ▫ Inadequate response of compensatory mechanisms to mechanical stressors eg:- during dehydration
- 40. Orthostatic syncope • Drop in BP > 20mmHg with increase of HR by >20 beats/ min while checking vitals in the supine to standing position • Lightheadedness and weakness after standing • Anemia, dehydration & medications (CCBs, ACEI) = predisposing factors
- 41. History • Patient and witnesses • Events • Duration/Symptoms • Past medical history • Medications • Family history
- 42. Physical Examination • Trauma without defensive injuries • Cardiovascular system ▫ Murmur ▫ Unequal blood pressures ▫ Orthostasis • Neurologic system ▫ Focal neurologic findings • Rectal Exam
- 43. History, Physical and ECG. . . .
- 44. ECG • Prior cardiopulmonary disease • Acute ischemia • Dysrhythmia • Heart block • Prolonged QT
- 45. Lab Testing • Dictated by H & P ▫ CBC ▫ Pregnancy test ▫ Electrolytes ▫ CXR ▫ Drug screen ▫ Ventilation-perfusion scan ▫ Abdominal/pelvic/carotid USG ▫ Exercise/Holter ECG
- 46. Syncope evaluation Directed studies suggested by initial eval . Cardiac -echo -monitor -serial ecg -enzyme study . Non-cardiac - tilt test - head ct/head mri - eeg - doppler study
- 47. Tilt test • Protocol ▫ supine for 30 mins ▫ tilt angle 60-80 degrees ▫ duration 30-45 mins ▫ provocation with isoproterenol, ntg, edrophonium, adenosine
- 48. Indications for tilt test• General agreement (assumes structural heart disease or other causes of syncope ruled out) recurrent syncope first episode, in pt at high risk exertional syncope
- 49. • Differences of opinion ▫ recurrent dizziness, falls ▫ peripheral neuropathy or dysautonomias ▫ repeat test to evaluate therapy
- 50. • Test not warranted ▫ single episode in pt at low risk, when clinical features clearly support dx of vasovagal etiology ▫ definitive dx of another etiology
- 51. • Test contraindicated ▫ critical aortic or mitral stenosis ▫ severe cad ▫ critical cerebrovascular disease
- 53. Disposition • Should they stay or should they go?
- 54. ACEP Task Force Recommendations • Admit patients with syncope and any of the following: ▫ A history of congestive heart failure or ventricular arrhythmia ▫ Associated chest pain or other symptoms compatible with acute coronary syndrome ▫ Evidence of significant congestive heart failure or valvular heart disease on physical examination ▫ ECG findings of ischemia, arrhythmia, prolonged QT interval, or bundle branch block
- 55. ACEP Recommendations • Consider admission for patients with syncope and any of the following: ▫ Age older than 60 years ▫ . History of coronary artery disease or congenital heart disease ▫ Family history of unexpected sudden death ▫ Exertional syncope in younger patients without an obvious benign etiology for the syncope
- 56. Predictors of Sudden Cardiac Death or Significant Dysrhythmia • 1. Abnormal ECG • 2. Age older than 45 years • 3. History of ventricular dysrhythmia • 4. History of congestive heart failure
- 57. European Heart Journal, May 2003 • Development and Prospective Validation of a Risk Stratification System for Patients With Syncope in the ED: The Oesil Risk Score ▫ 270 pts (syncope w/u: H&P, 12 lead, glucose, hgb) followed one year
- 58. ▫ Four independent risk factors: >65 years, hx cardiovascular dz, syncope w/o prodrome, abnormal ECG ▫ 1 (0.8- 8.5%). . . . . . 4 (52.9%)
- 59. Academic Emergency Medicine Dec 2003 • A Risk Score to Predict Arrhythmias in Patients with Unexplained Syncope ▫ <65 years, normal ECG, no Hx of CHF ▫ 0 (2%), 1 (17%), . . . . . . 3 (27%)
- 60. Summary • There are many causes of syncope • Be vigilant in ruling out the life-threatening ones! • Use the ultrasound machine • Take into account the risks of hospitalization