SyncopeAl Yaqdhan Al Atbi, MD

EM Resident

Outline

• Introduction• Importance• Pathophysiology • Etiology and DDx• Approach to a patient presented with syncope• Disposition

Introduction

• Syncope or Fainting:– a transient loss of consciousness, associated with

loss of postural tone, with spontaneous return to baseline neurologic function requiring no resuscitative efforts.

• Near-syncope:– a premonition of fainting without loss of

consciousness

Definition

Why it is Important• accounts for 0.8% of ED visits

• prevalence in the general population is 19%.

• Most causes of syncope are benign and have favorable outcomes.

• Recurrence of syncope may be as high as 50% and is not correlated with age or sex.

• The clinical examination (history and physical examination) alone can suggest the diagnosis in 45% of cases

• The overall U.S. medical cost of syncope is estimated at $2.4 billion annually

Pathophysiology

Etiologies

• Common causes according to Framingham Heart Study:– Vasovagal (reflex mediated, 21%)– cardiac (10%)– orthostatic (9%)– Medication related (7%)– Neurologic (4%)– unknown (37%).

After ED investigation, the unknown proportion may be 50% to 60%.

VASOVAGAL AND NEURALLY/REFLEX-MEDIATED SYNCOPE:

• In appropriate vagal and sympathetic tone– associated with inappropriate vasodilatation,

bradycardia, or both– lightheadedness, with or without nausea, pallor,

and/or sweating, and an associated feeling of warmth

• A slow, progressive onset with associated prodrome suggests vasovagal syncope.

• Exposure to certaine trigger may cause it.. Example:

• unpleasant sight, sound, or smell• Fear• severe pain• emotional distress• instrumentation

Situational syncope occurs during or immediately after coughing, micturition, defecation, or swallowing.

PSYCHIATRIC DISORDERS

• Organic causes should be rolled out first• 40% vasovagal syncope & 62% unknown• Most common Dx:– generalized anxiety disorder and major depressive

disorder

• Young> elderly

NEUROLOGIC SYNCOPE

• Rare• Patients with loss of consciousness with

persistent neurologic deficits or altered mental status do not have true syncope.

• Subclavian steal syndrome• Seizure

History

• Age• Syncopal attack:– Witnesses/unwitnessed– Onset , duration , recovary– Prior to attack– Attack– postsyncopal events– Associated symptoms

• Past medical hx• Medication HX

• Carotid Massage: Carotid sinus Syndrome• Hyperventilation Maneuver psychiatric (anxiety-provoking)

Disposition

• Inpatient:– If life threaten condition detected– Farther workup for high risk patient

• Out patient:– Low risk patients

Take Home Message

• Syncope is a common presentation in ED.• It can indicate for a life threaten conditions.• The ED evaluation of syncope is often

inconclusive

References

• Tintinalli’s• Rosen