Syncope resident survival guide

Jump to navigation Jump to search

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Karol Gema Hernandez, M.D. [2]

Definition

Syncope is defined as a transient LOC, characterized by rapid onset, short duration and spontaneous complete recovery due to cerebral hypoperfusion.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

Common Causes

Management

Syncope in the Context of Transient LOC

 
 
 
 
 
 
 
Determine if there was LOC
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If yes:
❑ Rapid onset?
❑ Short duration?
❑ Spontaneous complete recovery?
 
 
 
 
 
 
If no:
Cataplexy
❑ Drop attacks
❑ Falls
❑ Functional /psychogenic pseudosyncope
♦ Psychiatric evaluation
TIA of carotid origin
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If no to ≥1; exclude the following before proceeding with syncope evaluation:
Coma
❑ Aborted SCD
Epilepsy
-Perform neurological evaluation
-Perform tilt testing, preferably with concurrent EEG and video monitoring if doubt of mimicking epilepsy
❑ Metabolic disorders:
Hypoglycemia
Hypoxia
Hyperventilation with hypocapnia
Intoxication
❑ Vertebrobasilar TIA
 
If yes:
❑ Transient LOC
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Non traumatic
 
Traumatic
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Suspect:
❑ Syncope
Seizure
❑ Psychogenic
 
 
 
 
 
 

Diagnostic Flowchart in Patients with Suspected Syncope

 
 
 
 
 
 
 
 
 
❑ Initial Assessment:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Clinical history
❑ Physical examination (including supine and standing BP measurement after 3 minutes if OH is suspected)
EKG
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Syncope
 
 
 
 
 
T-LOC non syncopal
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Certain diagnosis
 
 
 
 
 
Uncertain etiology
 
❑ Confirm with specific test:
- EEG
- US of neck arteries
- Brain CT
- Brain MRI
OR
❑ Consult with specialist
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Risk stratification
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treatment
 
High risk:
❑ Early Evaluation and treatment
 
Low risk, recurrent syncopes:
❑ Cardiac or neurally mediated tests as appropriate OR
❑ Delayed treatment guided by EKG documentation
 
Low risk, single or rare syncope:
❑ No further evaluation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Specific etiology diagnostic evaluation
 
 
 
 
 
 
 



Algorithms based in 2009 ESC Guidelines for the Diagnosis and Management of Syncope. [3]

Do's

  • Tilt testing is indicated when it is of clinical value to demonstrate susceptibility to reflex syncope to the patient.
  • Tilt testing should be considered to discriminate between reflex and OH syncope.
  • Tilt testing may be considered for differentiating syncope with jerking movements from epilepsy.
  • If syncope happened after standing up position, there should be documentation with active standing or tilt testing in order to diagnose OH.
  • Perform CSM if patient >40 years with syncope of unknown aetiology after initial evaluation.
  • If multiple unexplained falls; perform tilt testing.
  • Consider ILR before embarking on cardiac pacing in patients with suspected or certain reflex syncope presenting with frequent or traumatic syncopal episodes.

Don'ts

  • CSM should be avoided in patients with previous TIA or stroke within the past 3 months and in patients with carotid sinus bruits (except if carotid sinus Doppler studies excluded significant stenosis.
  • Tilt testing is not recommended for assessment of treatment.
  • Isoproterenol tilt testing is contraindicaated in patients with ischaemic heart disease.
  • Owing to lack of correlation with spontaneous syncope, ATP test cannot be used as a diagnostic test to select patients for cardiac pacing.
  • If there is already indication for ICD in patients with ischemic heart with suspected arrhythmic cause don't perform EPS.

References

  1. Khoo, C.; Chakrabarti, S.; Arbour, L.; Krahn, AD. (2013). "Recognizing life-threatening causes of syncope". Cardiol Clin. 31 (1): 51–66. doi:10.1016/j.ccl.2012.10.005. PMID 23217687. Unknown parameter |month= ignored (help)
  2. Kapoor, WN. (2000). "Syncope". N Engl J Med. 343 (25): 1856–62. doi:10.1056/NEJM200012213432507. PMID 11117979. Unknown parameter |month= ignored (help)
  3. Task Force for the Diagnosis and Management of Syncope. European Society of Cardiology (ESC). European Heart Rhythm Association (EHRA). Heart Failure Association (HFA). Heart Rhythm Society (HRS). Moya A; et al. (2009). "Guidelines for the diagnosis and management of syncope (version 2009)". Eur Heart J. 30 (21): 2631–71. doi:10.1093/eurheartj/ehp298. PMC 3295536. PMID 19713422‎ Check |pmid= value (help).