Syncope(fainting)

Prepared by:Hemin Jamal

Supervised by:Dr. Aso Faiq

What is syncope

Sudden transient loss of consciousness with loss of postural tone(falling) which is followed by spontaneous and complete recovery.

Usually it is due to cerebral hypoperfusion.

Neurologic

Vasovagal syncope(pain,fear,Sight of blood) Situational(cough, defecation,micturition , swallowing….) Breath-holding spells

Causes

Cardiovascular Primary electrical disorder

Tachyarrthmia SVT,WPW VT Braddyarrhythmia Sick sinus syndrome Heart block Long QT syndrome

Outflow obstruction Aortic stenosis Hypertrophic obstructive cardiomyopathy Pulmonary hypertension Pulmonary stenosis

Poor contractility Congestive heart failure Myocarditis Dilated cardiomyopathy

Orthostatic hypotension Hypovolemia(dehydration) Adrenal Insufficiency

Other Anemia Hypoglycemia Medication ingestions Conversion disorder

PATHOPHYSIOLOGY

Cardiogenic

Neurogenic

History Patient: collapsed , passed out ,drop out It is syncope or not? (presyncope ,seizure) Precipitating factor( standing, pain, emotion fear ) Prodrome (sweating, pallor, dizziness, visual

change) Duration of unconsciousness

Was there associated chest pain, palpitations, or rapid heart rate

Were there symptoms of dehydration, vomiting, and diarrhea .

Past medical hx congenital heart disease, cardiac diseases

Drug hx; diuretics , beta blocker, Drugs prolonging QT interval

Family hx : Early cardiac death <45y Familial cardiomyopathy

Physical examination

1.Vital signs

Make sure to take orthostatic vital signs: heart rate and blood pressure in supine, sitting, and standing positions.

2. General hydration status, pallor suggesting anemia

3. Cardiac a. Systolic ejection murmurs: AS, hypertrophic obstructive cardiomyopathy b. S3 and S4 suggest heart failure

4. Neurologic: focal deficits, signs of increased intracranial pressure (ICP)/papilledema

1.Lab investigations

a. glucose and electrolytesb. hematocrit if history or physical examination suggests anemia

Investigations

2. ECG: evaluate for rate, rhythm, and conduction abnormalities.• Holter monitor• Stress ECG

3.Echocardiography: if needed, to evaluate for obstruction, structural abnormalities

• palpitations• syncope in the supine position.• absence of a prodrome.• Family history of sudden death,

• Syncope with exertion• Systolic ejection murmurs

arrhythmia Outflow obstruction

syncopeHistory and examination

ECG echocardiographyPediatric cardiologist

• Symptoms of dehydration, vomiting, and diarrhea suggesting hypovolemia.

• BP drop(>20) during standing.

• Episodes occurring after coughing, urination, defecation, or swallowing?

Orthostatic hypotension

Situational

SyncopeHistory and examination

• Rehydration• Non pharmacotherapy

• Reassurance• Non pharmacotherapy

• Triggered by prolonged standing, pain, or unpleasant environment

• Prodrome of sweating, nausea, vomiting, dizziness, feeling cold

Vasovagal attack

• Reassurance• Non pharmacotherapy

Non pharmacological

Avoidance of precipitating factors Awareness of prodrome Behavior modification with regard to changing position

from supine to standing Avoidance of volume depletion