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Revision as of 17:40, 26 March 2014 by Vidit Bhargava (talk | contribs)
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Characterize symptoms

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Medication history

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Past medical history

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Possible triggers

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Physical examination

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Labs and tests

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Imaging studies

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Diagnostic features

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Syncope

 
 
 
 
 
 
 
 
 

Non syncope loss of consciousness

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Known etiology
❑ Cardiovascular
❑ Orthostatic hypotension
❑ Reflex

 
 
 
 

Unknown etiology
Determine if there are any high risk criteria:

 
 
 
 

Consider additional tests

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

High risk

 
 
 

low risk

 

Consider alternative diagnoses

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Immediate in-hospital monitoring

 
 
 

Recurrent syncopes

 
 
 

Single syncope

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

If suspicion of structural hear disease:
Order an echocardiography

 
 
 
 
 

Was it in high risk setting?
❑ Potential risk of physical injury
❑ Occupational implications

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Structural heart disease present
Treat accordingly

 
 
 
 

No structural heart disease

 

Yes

 

No: No further evaluation

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Tilt testing

 
 
 
 
 
 
 


Characterize symptoms
Loss of consciousness (LOC)

❑ Rapid or slow onset
❑ Short or long duration
❑ Spontaneous complete recovery or incomplete recovery

Prodrome:

Diaphoresis
Nausea
Lightheadedness
Pallor
❑ Warmth
Blurry vision

Chest pain (suggestive of cardiovascular syncope)
Palpitations
❑ Position prior to LOC:

Supine (suggestive of cardiovascular syncope)
Supine to erect posture (suggestive of orthostatic hypotension or reflex syncope)
❑ Prolonged standing (suggestive of reflex syncope)

❑ Activity prior to LOC: (suggestive of cardiovascular or reflex syncope)

❑ Driving
❑ Machine operation
❑ Flying
❑ Competitive athletics

❑ Bowel or bladder incontinence (suggestive of reflex syncope)


Obtain a detailed past medical history:
❑ Previously healthy
❑ Previous syncope episodes

❑ Time since previous episode
❑ Number of previous episodes

❑ Cardiovascular disease:

Arrhythmia
Heart block (LBBB, RBBB)
Valvular heart disease
Heart failure
Hypertrophic cardiomyopathy
Cardiac tumor

❑ Neurological diseases:

Parkinson's disease
Diabetic neuropathy

Metabolic disorders (diabetes) ❑ Recent trauma


Identify possible triggers:
Suggestive of reflex syncope
Emotional stress
❑ Crowded places (agoraphobia)
❑ Warm weather
❑ Prolonged standing
Cough
Micturition
Defecation
Swallowing
❑ Head motion
❑ Arm motion
❑ Shaving

Suggestive of cardiovascular or orthostatic hypotension
Trauma
❑ Change in position
Fatigue
Exertion


Examine the patient Vitals
Heart rate

❑ Irregular rhythm (suggestive of AF)
Tachycardia (suggestive of orthostatic hypotension, cardiovascular or reflex syncope)
Bradycardia (suggestive of cardiovascular syncope)

Blood pressure:

❑ Measure in both arms, while standing and supine
Orthostatic hypotension (Fall in systolic BP ≥ 20 mmHg and/or in diastolic BP of at least≥ 10 mmHg between the supine and sitting BP reading)
Hypertension (suggestive of cardiovascular syncope)

Respiratory rate

Tachypnea (suggestive of reflex syncope)

Respiratory
Rales (suggestive of HF)

Cardiovascular
Palpitations (suggestive of arrhythmia)
Carotid bruits (suggestive of cardiovascular syncope)
Murmurs:

Aortic stenosis: crescendo-decrecendo systolic ejection murmur best heard at the upper right sternal border
Pulmonary stenosis: systolic ejection murmur best heard at the left second intercostal space

Heart sounds

❑ Loud P2 (suggestive of pulmonary hypertension)

Neurologic
Focal abnormalities (suggestive of stroke or cerebral mass)

Hemiparesis
Vision loss
Aphasia
Hypertonia

Glasgow coma scale
❑ Signs suggestive of Parkinson's disease:

Tremor
Rigidity
Bradykinesia/Akinesia
Postural instability
❑ Shuffling gait

Order labs and tests
EKG (most important initial test)

Myocardial infarction
Tachyarrhythmia
Heart block
Bradyarrhythmia
Long or short QT
Bradyarrhythmia

Electrolytes

Hyponatremia
Hypernatremia
Hypokalemia

Glucose (rule out hypoglycemia)
ABG

Hypoxia
Hypocapnea (suggestive of tachypnea, rule out psychiatric disease)


Order imaging studies
Echocardiography in case of:

Structural heart disease
Myocardial infarction
Cardiac valve disease

Head CT in case of:

Head trauma
TIA

Confirm diagnosis of syncope
Must have this 3 characteristics:
❑ Short duration
❑ Rapid onset
❑ Complete spontaneous recovery




Diagnostic criteria


Cardiovascular

Arrhythmia and cardiac ischemia-related syncope is diagnosed by EKG specific findings (Class I; Level of Evidence: C)
❑ Cardiovascular syncope is diagnosed when syncope presents with structural heart disease (Class I; Level of Evidence: C)

Orthostatic hypotension (OH)

❑ Diagnosed when syncope occurs after standing up and there is documentation of OH. (Class I; Level of Evidence: C)

Reflex

Vasovagal syncope: if is precipitated by emotional distress and is associated with typical prodrome. (Class I; Level of Evidence: C)
❑ Situational syncope: if occurs during or after specific triggers. (Class I; Level of Evidence: C)

Risk stratification


Determine if there are any high risk criteria:
❑ Severe structural heart disease
CAD
❑ Clinical or ECG features suggesting arrhythmic syncope:

Syncope during exertion or supine
Palpitations at the time of syncope
❑ Family history of SCD
❑ Non-sustained VT
❑ Conduction abnormalities with QRS >120 ms
Sinus bradycardia
❑ Pre-excited QRS complex
Long or short QT
Brugada pattern
ARVC

❑ Important comorbidities:

❑ Severe anemia
Electrolyte disturbance

Consider alternative diagnoses:
With loss of consciousness:

Coma (Glasgow coma scale < 8, profound state of unconsciousness)
Sudden cardiac arrest (absence of pulse)
Epilepsy (inquire past medical history)
❑ Findings: aura, prolonged confusion, muscle ache,
❑ Perform neurological evaluation (Class I; Level of Evidence: C)
❑ Perform tilt testing (Class IIb; Level of Evidence: C) , preferably with concurrent EEG and video monitoring if doubt of mimicking epilepsy
Intoxication
❑ Vertebrobasilar TIA


Without loss of consciousness:

Cataplexy
❑ Drop attacks
❑ Functional /psychogenic pseudosyncope
❑ Perform a psychiatric evaluation (Class I; Level of Evidence: C).
TIA of carotid origin


DrugAdult dosage
Inhaled Short Acting β Agonists (SABA)
Albuterol/Bitolterol/Pirbuterol
a) Nebulizer solution
b) MDI

♦ 2.5-5 mg every 20 minutes for 3 doses, then 2.5-10 mg every 1-4 hours as needed or 10-15 mg/hour continuously.
♦ 4-8 puffs every 20 mins upto 4 hours, then every 1-4 hours as needed.
Levalbuterol
a) Nebulizer solution
b) MDI

♦ 1.25-2.5 mg every 20 mins for 3 doses, then 1.25-5 mg every 1-4 hours as needed.
♦ 4-8 puffs every 20 mins upto 4 hours, then every 1-4 hours as needed.
Anticholinergics
Ipratropium bromide
a) Nebulizer solution
b) MDI

♦ 0.5 mg every 20 mins for 3 doses, then as needed.
♦ 8 puffs every 20 mins as needed for upto 3 hours.
Ipratropium with albuterol
a) Nebulizer solution (each 3 ml containing 0.5 mg ipratropium and 2.5 mg albuterol)
b) MDI (each puff contains 18 mcg ipratropium and 90 mcg albuterol)

♦ 3 ml every 20 mins for 3 doses, then as needed.
♦ 8 puffs every 20 mins as needed for 3 hours
Systemic corticosteroids
Prednisone/Prednisolone/Methylprednisolone ♦ 40-80 mg/day in 1 or 2 divided doses until peak expiratory flowrate (PEF) reaches 70% of personal best.


Clinical courseUnstable
Physical examination Signs of heart failure
Functional class IV
6MWD Less than 400 m
EchocardiogramRV Enlargement
HemodynamicsRAP high
CI low
BNPElevated/Increasing
TreatmentIntravenous prostacyclin and/or combination treatment
Frequency of evaluation Q 1 to Q 3 months
FC assessment Every clinic visit
6MWT Every clinic visit
Echocardiogram2Q 6 to Q 12 months/center dependent
BNPcenter dependent
RHCQ 6 to Q 12 months or clinical deterioration