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Syncope

Definition
Brief LOC associated with an inability to maintain postural tone that
spontaneously and completely resolves without medical intervention.

Without Medical Intervention Hypoxia/Hypoglcemia cannot explain syncope
because they resolve WITH Medical intervention (O2/Glucose)
Brief sycope lasts for less than minute, LOC is for 30min then that is not
syncope by definition
Completely If there are deficits post LOC then that is not syncope but
Stroke/TIA/Post Seizure Weakness

Pathophysiology
A lack of blood flow to both cerebral cortices or to the midbrain reticular
activating system (RAS) for 10 to 15 seconds leads to loss of
consciousness. Most commonly, an inciting event causes a drop in cardiac
output, which decreases oxygen and substrate delivery to the brain.

Life Threatening Causes
Cardiovascular: Arrythmias (See Below), Structural Heart Disease, ACS,
PE, Atrial Myxoma, TAD, Tamponade
Neurologic: Posterior Circulation TIA, SAH, ICH
Hemorrhage: Ectopic, GI Bleed

ED Management:
History is crucial to identify the cause for syncopy. Exertional Syncopy is
always high risk.
Make sure you are not dealing with a seizure! (Post-ictal confusion)
Start with ABCs
ECG: Only investigation that should be done for everyone with syncopy.
All other investigations are done only if needed based on the history.
Routine CT Head Very low yield if CNS exam is normal

On ECG: Look for
AV Blocks/Bradyarrythmias
Tachyarrythmias (SVT, AF, VT)
Brugada Syndrome (http://lifeinthefastlane.com/what-is-brugada-
syndrome/)
WPW Syndrome (http://lifeinthefastlane.com/ecg-library/pre-
excitation-syndromes/)
Long/Short QTc Syndrome (http://lifeinthefastlane.com/ecg-
library/basics/qt_interval/)
HOCM (http://lifeinthefastlane.com/ecg-library/hcm/)
ARVD (http://lifeinthefastlane.com/ecg-library/basics/arrhythmogenic-
right-ventricular-cardiomyopathy/)


Myth Orthostatic Vitals Predict Hypovolumia
Truth - Orthostatic Vitas are not very useful
Orthostatic vital signs alone to determine volume loss are highly
unreliable. Many patients can test positive for orthostatic signs even when
asymptomatic. The proportion of patients on beta blockers causing a blunting of
the testing would make this even more unreliable than it already is. Looking for
orthostatic clinical signs, not the numbers, is a far more reliable means to assess
volume loss. If the patient stands up and feels either lightheaded or passes out,
this is sufficient enough to determine significant hypovolemia.

Other tests done to evaluate Syncopy:
24 hour tape
Head CT
Tilt table testing
Psychiatric testing
EEG
Electrophysiological Testing

History and Exam:
What were you doing before the syncope?
What symptoms do you remember before and after syncope?
Any witnesses?
Recent illness?
Medications? Alcohol?
Prior history of syncope? Work up?
F/H/O SCD?
Associated Symptoms? (HA,CP,DIB,AP)

General Appearance, VS
HEENT, Cardiac (Systolic Murmur in young-HOCM, in Old-Aortic Stenosis)
Pulmonary
CNS (CN, Speech, Gait, Cerebellum)
Rectal Exam

Tongue Bite, Incontinence and Brief Convulsive movements can be seen in Syncopy
as well. Post Ictal Confusion strongly suggests Seizure.

High Risk Features (Strongly Consider Admission)
Abnormal ECG
H/O CHF
Hb<100
DIB with h/o CCF
Sudden Death in Family
Advanced Age

Risk Stratify based on History and Examination and decide on Disposition. Many
syncopy remain undiagnosed even after extensive evaluation by Cardio/Neuro.

Take Home
(Syncope = ECG + Good Hx and Physical Exam ---> Specific Work up and
risk stratificaton)
Routine labs in syncope seldom help - not cost-effective, and is not
supported by clinical evidence.
Workup must include hCG in females, everything else dictated by clinical
scenario

Syncope + headache= subarachnoid or intracranial hemorrhage
Syncope + neuro deficit= stroke/TIA or intracranial bleed
Syncope + confusion = seizure
Syncope + chest pain= MI, PE, or aortic dissection
Syncope + back/abdominal pain in older patient= abdominal aortic
aneurysm (AAA)
Syncope + positive HCG= ectopic pregnancy

Summary Prepared by Lakshay Chanana

Questions/Comments/Feedback

Lakshay Chanana
lakshay.chanana@nhs.net


References:

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healthy adults with moderate acute blood loss. Annals of emergency
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9. Unrecognized Killers in Emergency Electrocardiography Amal Mattu,
MD
10. Syncope Emergency evaluation and risk stratification Amal Mattu, MD
11. Syncope - A common Sense approach to a high risk problem Amal Mattu,
MD
12. Lifenthefastlane.com - EKGs
13. 19th AAEM Scientific Assembly 9-13 Feb 2013 Deadly Drops - Bart R
Besinger MD
14. RCEM - HALF A DOZEN THINGS TO KNOW ABOUT TRANSIENT LOSS OF
CONCIOUSNESS (BLACKOUTS)

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