Approach to Syncope 2018-01-30T16:37:04+00:00

Differentials

  • Cardiac
    • Arrhythmia
    • Aortic stenosis
    • HOCM
  • Respiratory
    • Pulmonary embolism
  • Neurological
    • Seizure
    • TIA / stroke
      • Tuberous sclerosis
      • Alcohol
      • Drug withdrawal
      • Electrolyte disturbance
      • Lack of sleep
      • Infection
        • Meningitis
        • Encephalitis
      • Scar epilepsy
    • Autonomic dysfunction (DM / Parkinson’s / MSA)
    • Intracranial haemorrhage
    • Brain tumour
  • Vasovagal
    • Dehydration
    • Carotid sinus hypersensitivity
    • Micturition syncope
    • Postural hypotension
  • Drugs
    • Benzodiazepines
    • Opiates
    • Unintentional overdose
  • Endocrine
    • Hypoglycaemia
    • Addison’s
  • Symptomatic anaemia
  • Vertebro-basilar insufficiency
    • Subclavian steal syndrome
  • Anxiety disorder

History

  • Syncopal episode
    • Is this the first time this has happened?
    • What were you doing when it happened?
    • Do you remember anything about the event?
    • Did anyone see it happen?
    • Did you notice any odd smells or sounds before it happened?
    • Did you feel light-headed before the attack?
    • Did you feel nauseous or sweaty?
    • Did you feel like you were about to faint?
    • Did you injure yourself when you fell?
    • What about your tongue?
    • Did you wet or soil yourself?
    • Do you remember what happened afterwards?
    • Were you confused?
    • Were you able to get up yourself and call for help?
  • Cardiovascular
    • Have you ever experienced a sensation of your heart beating very quickly?
    • Have you ever had any chest pain?
    • Has anyone in your family ever collapsed suddenly?
  • Neurological
    • Do you have any birth marks?
    • Have you had any injuries to your head recently?
    • Do you have a headache?
    • Have you noticed any blurred vision?
    • Have you noticed any tingling of your hands or feet?
    • Have you noticed any change in your sense of smell?
    • Have you noticed that it is difficult to get started when you want to do something?
    • Do you find that your movements are unusually slow?
    • Do you take any recreational drugs?
    • Do you drink any alcohol?
    • When was your last drink?
  • Situational syncope
    • Does this ever happen when you are passing urine?
    • Do you feel light headed if you turn your head to one side or another?
  • Dysautonomia
    • Do you find that you feel light-headed if you get up from a lying or sitting position?
    • Do you feel find that you feel full despite not having eaten much?
    • Has there been any change in your regular bowel motion?
    • Have you found it difficult to pass urine?
  • Respiratory
    • Have you noticed any swelling in your legs?
    • Do you use the oral contraceptive pill?
    • Have you been on any long flights recently?
  • Endocrine
    • Do you have, or have you ever had diabetes?
    • Are you on any medication for this?
    • Have you noticed that you are excessively thirsty?
    • Do you get up in the middle of the night to pass urine?
    • Have you noticed any change in the colour of your skin?
    • Do you feel unusually tired lately?

Examination

  • Vitals
    • Heart rate
    • Blood pressure / postural blood pressure
  • Inspection
    • Implantable cardiac device
    • Syndromic facies – e.g. myotonic dystrophy with complete heart block
    • Dermopathic changes consistent with diabetes
    • Skin changes consistent with tuberous sclerosis
    • Tremor
  • Pulse: rate, rhythm, volume, character
  • Cardiovascular
    • Carotid bruit
    • Apex beat location and character
    • Right ventricular heave
    • Ejection systolic murmur of hypertrophic obstructive cardiomyopathy
    • Ejection systolic murmur of aortic stenosis
  • Neurological
    • Pronator drift
    • Extra-ocular movements
    • Bradykinesia
    • Dysmetria
    • Intention tremor

Investigations

  • Electrocardiogram
    • Left ventricular hypertrophy
    • Arrhythmia
    • Heart block
  • Holter / REKA monitoring if degree of suspicion of arrhythmia is high
  • Blood tests
    • Electrolytes – arrhythmia
    • Full blood count – symptomatic anaemia
    • Blood glucose
    • Thyroid function tests
  • Electroencephalogram for seizure
  • Computed tomography scan of the brain for seizure (structural lesions)
  • Drug screen
  • Consider tilt table testing

Management

  • Patient education: advise not to drive until medically cleared to do so
  • Cardiac arrhythmia
    • May require permanent pacemaker if symptomatic heart block
    • May require implantable cardiac defibrillator if malignant arrhythmia
    • May require electrophysiological studies / accessory pathway ablation
  • Seizure
    • No need anti-epileptics if this is the first episode and no cause found
    • May recur in the future
    • Pregnancy counselling in women of child-bearing age
  • Vasovagal
    • Stay well hydrated
    • Avoid rapid changes in position
  • Endocrine
    • Adjust medication to avoid hypoglycaemia
    • Patient education on symptoms of hypoglycaemia and how to avoid it

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This Sliding Bar can be switched on or off in theme options, and can take any widget you throw at it or even fill it with your custom HTML Code. Its perfect for grabbing the attention of your viewers. Choose between 1, 2, 3 or 4 columns, set the background color, widget divider color, activate transparency, a top border or fully disable it on desktop and mobile.