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Syncope

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Common reason to present to ER or to ambulatory clinic ... Rare disorders Addison's, panhypopit, Shy-Drager. Workup: Take home points ... – PowerPoint PPT presentation

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Title: Syncope


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Syncope or Near Syncope
  • Differential Diagnosis and Cost Effective Workup

4
Syncope
  • Common reason to present to ER or to ambulatory
    clinic
  • Transient loss of consciousness that is
    accompanied by loss of postural tone
  • Due to transient hypoperfusion of the brain (from
    numerous causes)
  • Near syncope?similar workup
  • Rarely necessitates hospital admission
  • Etiology broadly divided into three categories
  • head, heart, and vessels

5
Head
  • Primary neurologic events seizures (atonic
    seizures, temporal lobe seizures, unwitnessed
    grand mal seizures)
  • Psychiatric illness anxiety, panic attack,
    conversion disorder
  • Neurally mediated events reflex mechanisms that
    are associated with inappropriate vasodilatation,
    bradycardia, or both.
  • --includes vasovagal, vasodepressor,
    situational, carotid sinus syndrome

6
Heart
  • Cardiac related events that cause a sudden drop
    in cardiac output and therefore syncope
  • --tachyarrthymia (SVT, VT, torsades with long
    QT)
  • --bradyarrythmias
  • --PE (sizable)
  • --atrial myxoma
  • --ischemia
  • --inability to increase cardiac output with
    activity IHSS, aortic stenosis

7
Vessels (Orthostatic Hypotension)
  • Medication related (antihypertensives, others)
  • Autonomic insufficiency
  • Dehydration/volume depletion
  • Exaggerated physiologic response (hot tub
    syncope, esp after EtOH)
  • Rare disordersAddisons, panhypopit, Shy-Drager

8
Workup Take home points
  • Shot gun approach not helpful
  • Patients remain undiagnosed in 34 of cases
  • Most common to least common diagnosis
    vasovagal, cardiac arrhythmia, orthostatic
    hypotension, seizure
  • Therefore, directed (and thorough) history and
    physical and an EKG can pinpoint the problem in
    most cases

9
History
  • What exactly was the patient doing (positional,
    exertional, situational)
  • Any prodrome
  • Postictal symptoms
  • Medication history
  • Interview family or witnesses

10
PE
  • Check Orthostatic BP
  • Cardiac exammurmur of AS/IHSS, tumor plop,
    pulmonary HTN with RVH
  • Thorough neurologic exam
  • EKG look for old infarcts, BBB, AV block

11
What about other tests?
  • Labs rarely useful electrolytes may reveal low
    K/Mg/Na/Ca, renal failure, or
    hypo/hyperglycemia
  • These are rare to cause an event in and of
    themselves, but can point to other etiology
    (seizure)
  • Head CT, EEG only if focal neurologic findings
    or if prior history of seizure
  • Carotid dopplers appropriate in the presence of
    bruits or when the history suggests VBI

12
What if initial evaluation is negative?
  • First, reassure patient (recall that a third
    remain undiagnosed prognosis is generally good)
  • If suspected heart disease or risk factors for
    heart disease echo, exercise stress test,
    Holter monitor
  • Elderly patients same as above but consider
    polypharmacy, situational syncope
  • Younger patients not known or suspected to have
    heart disease ambulatory loop ECG, tilt table
    testing, and psychiatric evaluation for
    anxiety/panic disorder
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