Syncope resident survival guide: Difference between revisions
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[[Syncope]] is | |- | ||
! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Syncope Resident Survival Guide Microchapters}} | |||
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Syncope resident survival guide#Overview|Overview]] | |||
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Syncope resident survival guide#Causes|Causes]] | |||
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Syncope resident survival guide#Classification|Classification]] | |||
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Syncope resident survival guide#FIRE: Focused Initial Rapid Evaluation|FIRE]] | |||
|- | |||
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left |[[Syncope resident survival guide#Complete Diagnostic Approach|Complete]] | |||
: [[Syncope resident survival guide#Diagnostic Clues|Clues]] | |||
|- | |||
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Syncope resident survival guide#Treatment|Treatment]] | |||
|- | |||
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Syncope resident survival guide#Do's|Do's]] | |||
|- | |||
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Syncope resident survival guide#Don'ts|Don'ts]] | |||
|} | |||
==Overview== | |||
[[Syncope]] is the transient [[LOC|loss of consciousness]] ([[LOC]]) due to cerebral hypoperfusion and it is characterized by a rapid onset, a short duration and a spontaneous complete recovery. It is important to identify the cause of [[syncope]] and recognize high risk patients with [[structural heart disease]] or abnormal [[ECG]] findings. The initial management of [[syncope]] depends on the etiology of the [[syncope]] which can be either reflex, [[orthostatic hypotension]] or [[Syncope causes#Causes#Causes by Organ System|cardiovascular]]. | |||
==Causes== | ==Causes== | ||
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===Common Causes=== | ===Common Causes=== | ||
*[[Aortic stenosis]] | |||
*[[Arrhythmia]] | *[[Arrhythmia]] | ||
*[[ | *[[Medications]] ([[vasodilators]], [[diuretics]], [[antiarrhythmics]], [[antipsychotics]]) | ||
*[[Orthostatic hypotension]] | *[[Orthostatic hypotension]] | ||
*[[Vagal stimulation]] | *[[Vagal stimulation]] | ||
*[[Vertebrobasilar insufficiency]]<ref name="Kapoor-2000">{{Cite journal | last1 = Kapoor | first1 = WN. | title = Syncope. | journal = N Engl J Med | volume = 343 | issue = 25 | pages = 1856-62 | month = Dec | year = 2000 | doi = 10.1056/NEJM200012213432507 | PMID = 11117979 }}</ref> | *[[Vertebrobasilar insufficiency]]<ref name="Kapoor-2000">{{Cite journal | last1 = Kapoor | first1 = WN. | title = Syncope. | journal = N Engl J Med | volume = 343 | issue = 25 | pages = 1856-62 | month = Dec | year = 2000 | doi = 10.1056/NEJM200012213432507 | PMID = 11117979 }}</ref> | ||
==Management== | Click '''[[Syncope causes|here]]''' for the complete list of causes. | ||
===Syncope in the | |||
==Classification== | |||
[[Syncope]] is classified based on the pathophysiology of the etiology.<ref name="pmid19713422">{{cite journal| author=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.| title=Guidelines for the diagnosis and management of syncope (version 2009). | journal=Eur Heart J | year= 2009 | volume= 30 | issue= 21 | pages= 2631-71 | pmid=19713422 | doi=10.1093/eurheartj/ehp298 | pmc=PMC3295536 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19713422 }} </ref> | |||
====Cardiovascular Syncope==== | |||
* [[Arrhythmias]] ([[bradycardia]] or [[tachycardia]]) | |||
* [[Structural heart disease]] | |||
* [[Drug]]-induced arrhythmia | |||
====Orthostatic Hypotension==== | |||
* Primary autonomic failure ([[pure autonomic failure]], [[Parkinson's disease]]) | |||
* Secondary autonomic failure ([[diabetes]], [[uremia]]) | |||
* [[Drug]]-induced ([[alcohol]], [[vasodilators]], [[diuretics]]) | |||
* [[Hypovolemia]] ([[hemorrhage]], [[diarrhea]]) | |||
====Reflex Syncope==== | |||
* [[Vasovagal syncope|Vasovagal]] | |||
* [[Situational syncope]] ([[cough]], [[sneeze]], postprandial, post-exercise) | |||
* [[Carotid sinus hypersensitivity]] | |||
==FIRE: Focused Initial Rapid Evaluation== | |||
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention. | |||
<span style="font-size:85%">Boxes in the red signify that an urgent management is needed.</span> | |||
<span style="font-size:85%">'''Abbreviations:''' '''CT''': Computed tomography; '''DVT''': Deep vein thrombosis; '''ECG:''' electrocardiogram; '''STEMI''': ST elevation myocardial infarction</span> | |||
{{Family tree/start}} | |||
{{familytree | | | | | | | | | D01 | | | | | | | | | D01=<div style="text-align: center; width: 20em"> '''Identify cardinal findings that increase the pretest probability of syncope'''</div><br><div style="text-align: left; width: 15em"> ❑ [[Loss of consciousness]](LOC) of: | |||
: ❑ Short duration, | |||
: '''AND''' | |||
: ❑ Rapid onset, | |||
: '''AND''' | |||
: ❑ Complete spontaneous recovery<ref name="pmid19713422">{{cite journal| author=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.| title=Guidelines for the diagnosis and management of syncope (version 2009). | journal=Eur Heart J | year= 2009 | volume= 30 | issue= 21 | pages= 2631-71 | pmid=19713422 | doi=10.1093/eurheartj/ehp298 | pmc=PMC3295536 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19713422 }} </ref> </div>}} | |||
{{familytree | | | | | | | | | |!| | | | | | | | | | }} | |||
{{familytree | | | | | | | | | X01 | | | | | | | | | | X01= <div style="float: left; text-align: left; width: 20em; padding:1em;">'''Differentiate syncope from other common similar presentations without LOC'''<br> ❑ [[Vertigo]] <br> ❑ [[Lightheadedness]] <br> ❑ [[Epilepsy]] <br> ❑ [[Hypoglycemia]] </div>}} | |||
{{familytree | | | | | | | | | |!| | | | | | | | | | }} | |||
{{familytree | | | | | | | | | A01 | | | | | | | | | | A01= <div style="float: left; text-align: left; width: 20em; padding:1em;">'''Does the patient have any of the findings that require urgent management?'''<br> | |||
❑ [[Tachycardia]] <br> ❑ [[Hypotension]]<br>❑ Severe [[dyspnea]]<br> ❑ [[Hemorrhage]] <br> ❑ [[Seizures]]</div>}} | |||
{{familytree | | | | | | |,|-|-|^|-|-|.| | | | |}} | |||
{{familytree | | | | | | B01 | | | | B02 | | | | B01=<div style=" background: #FA8072; text-align: center; width: 15em; padding:1em;"> {{fontcolor|#F8F8FF|'''Yes'''}} </div>| B02= '''No'''}} | |||
{{familytree | | | | | | |!| | | | | |!| | | | }} | |||
{{familytree | | | | | | C01 | | | | C02 | | | | C01=<div style=" background: #FA8072; text-align: left; width: 15em; padding:1em;"> {{fontcolor|#F8F8FF| ❑ Immediately order an [[ECG|<span style="color:white;">ECG</span>]]}}<br><br></div> | C02=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''[[Syncope resident survival guide#Complete Diagnostic Approach|Continue with the complete diagnostic approach below]]''' </div>}} | |||
{{familytree | | | | | | |!| | | | | | | | | | }} | |||
{{familytree | | | | | | G01 | | | | | | | | | G01=<div style=" background: #FA8072; text-align: center; width: 15em; padding:1em;"> {{fontcolor|#F8F8FF| '''[[ECG|<span style="color:white;">ECG</span>]] findings'''}}</div>}} | |||
{{familytree | | |,|-|-|-|+|-|-|-|.| | | | |}} | |||
{{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | F01 | | F02 | | F03 | | | | F01=<div style=" width: 15em; padding:1em;"> <div style="background: #FA8072"> {{fontcolor|#F8F8FF| '''[[Arrhythmia|<span style="color:white;">Arrhythmia </span>]]''' }} </div> </div>| F02=<div style=" width: 15 em"> <div style="background: #FA8072"> {{fontcolor|#F8F8FF| '''[[Myocardial infarction|<span style="color:white;">Myocardial infarction</span>]]'''}} </div> </div>| F03=<div style=" width: 20 em"> <div style="background: #FA8072"> {{fontcolor|#F8F8FF| '''Normal [[ECG|<span style="color:white;">ECG</span>]]'''}} </div> </div>}} | |||
{{familytree | | |!| | | |!| | |,|^|-|-|.| | | | |}} | |||
{{familytree | | |!| | | |!| | G02 | | G03 | | | | G02= <div style="background: #FA8072"> {{fontcolor|#F8F8FF|'''[[Hemorrhage|<span style="color:white;">Hemorrhage</span>]]'''}}</div>| G03=<div style="background: #FA8072">{{fontcolor|#F8F8FF|'''[[Pulmonary embolism|<span style="color:white;">Pulmonary embolism</span>]]'''}}</div>}} | |||
{{familytree | | |!| | | |!| | |!| | | |!| | | |}} | |||
{{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | | |!| | H02 | | H03 | | H04 | | H02=<div style=" width: 15em; text-align:left"> <div style="background: #FA8072"> {{fontcolor|#F8F8FF| '''Administer:'''<br> ❑ [[Aspirin|<span style="color:white;">Aspirin</span>]] 162-325 mg <br> ❑ [[Oxygen therapy|<span style="color:white;">Oxygen </span>]](2-4 L/min) if satO2 <90% <br> ❑ [[Beta blockers|<span style="color:white;">Beta blockers</span>]] (unless contraindicated) <br> ❑ Sublingual [[nitroglycerin|<span style="color:white;">nitroglycerin</span>]] 0.4 mg every 5 min for a total of 3 doses <br> '''Do not delay [[primary angioplasty|<span style="color:white;">primary angioplasty</span>]] or [[fibrinolysis|<span style="color:white;">fibrinolysis</span>]]'''}} </div> </div>| H03=<div style="text-align:left; width: 20em"> ❑ Manage the hypovolemic state <br> | |||
: ❑ Administer IV normal saline 2 L | |||
: ❑ Give [[vasoconstrictor|<span style="color:white;">vasopressors</span>]] if needed | |||
❑ Determine the location and etiology of the [[bleeding|<span style="color:white;">bleeding</span>]]</div> | H04=<div style="text-align:left"> Suggestive signs and symptoms:<br> ❑ Sudden onset of [[dyspnea|<span style="color:white;">dyspnea</span>]] and [[tachypnea|<span style="color:white;">tachypnea</span>]] <br>❑ [[Tachycardia|<span style="color:white;">Tachycardia</span>]] <br>❑ [[Pleuritic chest pain|<span style="color:white;">Pleuritic chest pain</span>]] <br>❑ Symptoms suggestive of [[DVT|<span style="color:white;">DVT</span>]]<br>❑ Positive CT [[pulmonary angiography|<span style="color:white;">pulmonary angiography</span>]] </div>}} | |||
{{familytree | | |!| | | |!| | |!| | | | |!| | | |}} | |||
{{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | I00 | | I01 | | I02 | | I03 | | I00=<div style=" width:15em"> <div style="background: #FA8072"> '''[[Arrhythmia resident survival guide|<span style="color:white;">Click here for arrhythmia resident survival guide</span>]]''' </div> </div>|I01=<div style=" width: 15em"> <div style="background: #FA8072"> '''[[STEMI resident survival guide|<span style="color:white;">Click here for STEMI resident survival guide</span>]]''' </div> </div>|I02=<div style=" width: 15em"> <div style="background: #FA8072"> '''[[Shock resident survival guide|<span style="color:white;">Click here for shock resident survival guide</span>]]''' </div> </div>| I03=<div style="text-align:left; width:15em">'''[[Pulmonary embolism resident survival guide|<span style="color:white;">Click here for pulmonary embolism resident survival guide</span>]]''' </div>}} | |||
{{Family tree/end}} | |||
<br><br> | |||
==Complete Diagnostic Approach== | |||
A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.<ref name="pmid19713422">{{cite journal| author=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.| title=Guidelines for the diagnosis and management of syncope (version 2009). | journal=Eur Heart J | year= 2009 | volume= 30 | issue= 21 | pages= 2631-71 | pmid=19713422 | doi=10.1093/eurheartj/ehp298 | pmc=PMC3295536 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19713422 }} </ref><ref name="Strickberger2006">{{cite journal|last1=Strickberger|first1=S. A.|title=AHA/ACCF Scientific Statement on the Evaluation of Syncope: From the American Heart Association Councils on Clinical Cardiology, Cardiovascular Nursing, Cardiovascular Disease in the Young, and Stroke, and the Quality of Care and Outcomes Research Interdisciplinary Working Group; and the American College of Cardiology Foundation: In Collaboration With the Heart Rhythm Society: Endorsed by the American Autonomic Society|journal=Circulation|volume=113|issue=2|year=2006|pages=316–327|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.105.170274}}</ref> | |||
<span style="font-size:85%"> '''Abbreviations:''' '''AF:''' atrial fibrillation; '''ARVC:''' arrhythmogenic right ventricular cardiomyopathy; '''BBB:''' bundle branch block; '''CAD:''' coronary artery disease; '''EEG:''' electroencephalography; '''HF:''' heart failure; '''MI:''' myocardial infarction; '''SCD:''' sudden cardiac death'''; SVT:''' supraventricular tachycardia; '''TIA:''' transient ischemic attack; '''VT:''' ventricular tachycardia </span> | |||
{{familytree/start}} | {{familytree/start}} | ||
{{familytree | | | | | | | | | {{familytree | | | | | | | A01 | | A01= <div style="float: left; text-align: left; width: 20em; padding:1em;">'''Characterize the symptoms:'''<br> | ||
{{familytree | | | | | | ❑ [[Loss of consciousness]] (LOC) | ||
{{familytree | | | | :❑ Rapid or slow onset | ||
{{familytree | |,|-|^|-|.| | | | | | | | | }} | :❑ Short or long duration | ||
{{familytree | | :❑ Spontaneous complete recovery or incomplete recovery | ||
{{familytree | ❑ [[Prodrome]] | ||
{{familytree | | | | : ❑ [[Diaphoresis]] | ||
{{familytree | | | | : ❑ [[Nausea]] | ||
{{familytree | | | | : ❑ [[Lightheadedness]] | ||
: ❑ [[Pallor]] | |||
: ❑ Warmth | |||
: ❑ [[Blurry vision]]<br> | |||
❑ [[Chest pain]] (suggestive of cardiovascular [[syncope]]) <br> | |||
❑ [[Palpitations]] <br> | |||
❑ 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]])<br> | |||
❑ Activity prior to [[LOC]] (suggestive of cardiovascular or reflex [[syncope]]) | |||
: ❑ Driving | |||
: ❑ Machine operation | |||
: ❑ Flying | |||
: ❑ Competitive athletics <br> | |||
❑ Bowel or bladder [[incontinence]] (suggestive of reflex syncope) </div>}} | |||
{{familytree | | | | | | | |!| | | }} | |||
{{familytree | | | | | | | M01 | | M01= <div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Inquire about medications that can cause syncope:'''<br> | |||
❑ [[Nitrates]] (decrease [[preload]])<br> | |||
❑ [[Diuretics]]<br> | |||
❑ [[Antiarrhythmic]]<br> | |||
❑ [[Alpha blocker]]<br> | |||
❑ [[Beta blocker]]<br> | |||
❑ [[ACE inhibitors]] <br> | |||
❑ [[ARB]]<br> | |||
❑ [[Hydralazine]]<br> | |||
❑ [[Ethanol]]<br> | |||
❑ [[Benzodiazepines]]<br> | |||
❑ [[Antipsychotics]]<br> | |||
❑ [[Tricyclic antidepressants]]<br> | |||
❑ [[Barbiturates]] </div>}} | |||
{{familytree | | | | | | | |!| | | }} | |||
{{familytree | | | | | | | L01 | | L01= <div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Obtain a detailed past medical history:'''<br> | |||
❑ Previous [[syncope]] episodes | |||
: ❑ Time since previous episode | |||
: ❑ Number of previous episodes <br> | |||
❑ 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]] </div> }} | |||
{{familytree | | | | | | | |!| | | }} | |||
{{familytree | | | | | | | B01 | | B01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Identify possible triggers:''' <br> | |||
''Suggestive of reflex [[syncope]]''<br> | |||
❑ [[Stress|Emotional stress]]<br> | |||
❑ Crowded places ([[agoraphobia]])<br> | |||
❑ Warm weather<br> | |||
❑ Prolonged standing<br> | |||
❑ [[Cough]]<br> | |||
❑ [[Micturition]]<br> | |||
❑ [[Defecation]]<br> | |||
❑ [[Swallowing]]<br> | |||
❑ Rapid head motion<br> | |||
❑ Placing arms over the head<br> | |||
❑ Shaving<br> | |||
''Suggestive of cardiovascular or [[orthostatic hypotension]]''<br> | |||
❑ [[Trauma]]<br> | |||
❑ Change in position <br> | |||
❑ [[Fatigue]]<br> | |||
❑ [[Exertion]] | |||
</div>}} | |||
{{familytree | | | | | | | |!| | | }} | |||
{{familytree | | | | | | | Z01 | | Z01= <div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Examine the patient:''' | |||
'''Vitals'''<br> | |||
❑ [[Heart rate]] | |||
: ❑ Irregularly irregular rhythm (suggestive of [[AF]]) | |||
: ❑ [[Tachycardia]] (suggestive of [[orthostatic hypotension]], cardiovascular or reflex [[syncope]]) | |||
: ❑ [[Bradycardia]] (suggestive of cardiovascular [[syncope]]) | |||
❑ [[Blood pressure]]<br> | |||
: ❑ 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''' <br> | |||
❑ [[Rales]] (suggestive of [[HF]]) <br> | |||
'''Cardiovascular'''<br> | |||
❑ [[Palpitations]] (suggestive of [[arrhythmia]]) <br> ❑ [[Carotid bruits]] (suggestive of cardiovascular syncope) <br> ❑ [[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 <br> | |||
❑ [[Heart sounds]] | |||
: ❑ Loud P2 (suggestive of [[pulmonary hypertension]]) | |||
'''Neurologic'''<br> | |||
❑ [[focal neurologic signs|Focal abnormalities]] (suggestive of [[stroke]] or [[cerebral mass]]) | |||
: ❑ [[Hemiparesis]] | |||
: ❑ [[Vision loss]] | |||
: ❑ [[Aphasia]] | |||
: ❑ [[Hypertonia]] | |||
❑ [[Glasgow coma scale]] <br> | |||
❑ Signs suggestive of [[Parkinson's disease]]: | |||
: ❑ [[Tremor]] | |||
: ❑ [[Spasticity|Rigidity]] | |||
: ❑ [[Bradykinesia]]/[[Akinesia]] | |||
: ❑ [[Postural instability]] | |||
: ❑ Shuffling gait </div> }} | |||
{{familytree | | | | | | | |!| | | }} | |||
{{familytree | | | | | | | G01 | | G01= <div style="float: left; text-align: left; width: 20em; padding:1em;">'''Order labs and tests:''' <br> ❑ [[EKG]] ''(most important initial test)'' | |||
: ❑ [[Myocardial infarction]] | |||
: ❑ [[Tachyarrhythmia]] | |||
: ❑ [[Heart block]] | |||
: ❑ [[Bradyarrhythmia]] | |||
: ❑ [[long QT|Long]] or [[short QT syndrome|short QT]] | |||
: ❑ [[Bradyarrhythmia]] | |||
❑ [[Electrolytes]] | |||
: ❑ [[Hyponatremia]] | |||
: ❑ [[Hypernatremia]] | |||
: ❑ [[Hypokalemia]] | |||
❑ [[Glucose]] (rule out [[hypoglycemia]]) <br> ❑ [[ABG]] | |||
: ❑ [[Hypoxia]] | |||
: ❑ [[Hypocapnea]] (suggestive of [[tachypnea]], rule out psychiatric disease)</div> }} | |||
{{familytree | | | | | | | |!| | | }} | |||
{{familytree | | | | | | | H01 | | H01= <div style="float: left; text-align: left; width: 20em; padding:1em;">'''Order imaging studies:'''<br> ❑ '''[[Echocardiography]]''' ''in case of:'' | |||
:: ❑ [[Structural heart disease]] | |||
:: ❑ [[Myocardial infarction]] | |||
:: ❑ [[Cardiac valve disease]]<br> | |||
❑ '''Head [[CT]]''' ''in case of:'' | |||
:: ❑ [[Head trauma]] | |||
:: ❑ [[TIA]]</div> }} | |||
{{familytree | | | | | | | |!| | | }} | |||
{{familytree | | | | | | | U01 | | U01= '''Confirm diagnosis of syncope''' <br> ''Must have this 3 characteristics:'' <br> <div style="text-align: left"> ❑ Short duration, AND <br> ❑ Rapid onset, AND <br> ❑ Complete spontaneous recovery </div>}} | |||
{{familytree | | | | |,|-|-|^|-|.| | | | }} | |||
{{familytree | | | | C01 | | | | C02 | | C01= <div style=" width: 15em">'''Syncope'''</div>| C02= <div style=" width: 15em">'''Non-syncopal [[LOC]]''' </div>}} | |||
{{familytree | |,|-|-|^|-|.| | | |!| | | }} | |||
{{familytree | D01 | | | D02 | | D03 | | D01= '''Known etiology'''| D02= '''Unknown etiology''' | D03=<div style="text-align:left">'''Consider additional tests'''<br> | |||
❑ [[Stool guaiac test]] (rule out [[GI bleeding]]) <br> ❑ Blood and urine toxicology tests (rule out [[intoxication]]) </div> }} | |||
{{familytree | |!| | | | |!| | | |!| | | }} | |||
{{familytree | F01 | | | F02 | | F03 | | F01=<div style="text-align: left; width: 20em">'''Determine the etiology:'''<br> ❑ '''Cardiovascular''' | |||
: ❑ [[Arrhythmia]] | |||
: ❑ [[Ischemia|Cardiac ischemia]] | |||
: ❑ [[Structural heart disease]] | |||
❑ '''[[Orthostatic hypotension]]''' | |||
: ❑ [[Syncope]] after standing up and documentation of [[orthostatic hypotension]] ([[ESC#Classes of Recommendations|Class I; Level of Evidence: C]])<br> | |||
❑ '''Reflex''' | |||
: ❑ [[Vasovagal syncope]] precipitated by emotional distress and associated with typical [[prodome]] ([[ESC#Classes of Recommendations|Class I; Level of Evidence: C]]) | |||
: ❑ Situational [[syncope]] during or after specific [[Vasovagal syncope#Triggers|triggers]] ([[ESC#Classes of Recommendations|Class I; Level of Evidence: C]]) </div> | F02=<div style="float: left; text-align: left;"> '''Determine if there are any high risk criteria:''' <br> ❑ Severe [[structural heart disease]] <br> ❑ [[CAD]]<br> ❑ Clinical or [[ECG]] features suggesting arrhythmic syncope <br> | |||
: ❑ [[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]] | |||
: ❑ [[Preexcitation syndrome]] | |||
: ❑ [[long QT|Long]] or [[short QT syndrome|short QT]] | |||
: ❑ [[Brugada syndrome|Brugada pattern]] | |||
: ❑ [[ARVC]] | |||
❑ Important comorbidities | |||
: ❑ Severe [[anemia]] | |||
: ❑ [[Electrolyte disturbance]] </div> | F03=<div style="float: left; text-align: left; width:20em">'''Consider alternative diagnoses:''' | |||
<br> | |||
❑ '''With loss of consciousness''' <br> | |||
: ❑ [[Epilepsy]] | |||
:: ❑ Inquire about suggestive signs include [[aura]], prolonged [[confusion]], [[muscle ache]] | |||
:: ❑ Inquire about past medical history | |||
:: ❑ Perform neurological evaluation ([[ESC#Classes of Recommendations|Class I; Level of Evidence: C]]) | |||
:: ❑ Perform [[tilt test|tilt testing]] ([[ESC#Classes of Recommendations|Class IIb; Level of Evidence: C]]), preferably with concurrent [[EEG]] and video monitoring if doubt of mimicking epilepsy <br> | |||
: ❑ [[Intoxication]] | |||
: ❑ Vertebrobasilar [[TIA]] | |||
<br> | |||
❑ '''Without loss of consciousness''' | |||
: ❑ [[Vertigo]] | |||
:: ❑ Perform the [[Dix-Hallpike test]] to diagnose [[BPPV]] | |||
: ❑ [[Lightheadedness]] | |||
: ❑ [[Cataplexy]] | |||
: ❑ [[Drop attack]]s | |||
: ❑ Functional /psychogenic pseudosyncope | |||
:: ❑ Perform a psychiatric evaluation ([[ESC#Classes of Recommendations|Class I; Level of Evidence: C]]) | |||
: ❑ [[TIA]] of [[carotid]] origin </div>}} | |||
{{familytree | | | | | | |!| | | | | | |}} | |||
{{familytree | |,|-|-|-|-|^|-|.| | | | | | }} | |||
{{familytree | G01 | | | | | G02 | | | | | | | G01= '''High risk''' |G02= '''Low risk''' }} | |||
{{familytree | |!| | | | | | |!| | | | | | }} | |||
{{familytree | S01 | |,|-|-|-|^|-|-|.| | | | S01= <div style="float: left; text-align: left; width: 20em"> ❑ Immediate in-hospital monitoring (in bed or telemetry) to look for abnormalities suggestive of arrhythmic syncope ([[ESC#Classes of Recommendations|Class I; Level of Evidence: B]]) </div> | }} | |||
{{familytree | | | | |!| | | | | | |!| | | | | }} | |||
{{familytree | | | | H01 | | | | | H02 | | | | | H01= '''Recurrent episodes of syncope''' <br> <div style="float: left; text-align: left; width:20em"> ❑ Order a [[Holter]] if > 1 episode/week ([[ESC#Classes of Recommendations|Class I; Level of Evidence: B]]) <br> ❑ Order external loop recorder (ELR) if interval between episodes < 4 weeks ([[ESC#Classes of Recommendations|Class IIa; Level of Evidence: B]])<br> ❑ Perform [[carotid sinus massage]] in patients > 40 years with uncertain syncopal etiology ([[ESC#Classes of Recommendations|Class I; Level of Evidence: B]])<br> | |||
: <span style="font-size:85%;color:red"> Contraindicated in patients with previous TIA or stroke in the past 3 months <br> Contraindicated in patients with carotid bruits </span></div> |H02= '''Single episode of syncope''' }} | |||
{{familytree | | | | |!| | | | | | |!| | | }} | |||
{{familytree | | | | I01 | | | | | I02 | | | I01= <div style="float: left; text-align: left; width: 20em">'''In case of suspicion of structural heart disease:''' <br> ❑ Order an [[echocardiography]] ([[ESC#Classes of Recommendations|Class I; Level of Evidence: B]])</div> | I02= '''Is any of the following high risk setting present?''' <br> ❑ Potential risk of physical injury <br> ❑ Occupational implications }} | |||
{{familytree | | |,|-|^|-|.| | | |,|-|^|-|.| | }} | |||
{{familytree | J01 | | J02 | | J03 | | J04 | | J01= Presence of [[structural heart disease]] | J02= Absence of [[structural heart disease]] | J03=<div style="width: 10em"> Yes </div> | J04=No}} | |||
{{familytree | |!| | | | |!| |!| | | | |!| | }} | |||
{{familytree | T00 | | | | T01 | | | | T02 | | T00= ❑ Treat accordingly| T01= '''Perform a [[tilt test]]''' ([[ESC#Classes of Recommendations|Class I; Level of Evidence: B]])| T02= No further investigation}} | |||
{{familytree | | | | | | | |!| | | | | | }} | |||
{{familytree | | | | | | | U01 | | | | | U01= <div style="float: left; text-align: left"> ❑ No findings, OR <br> ❑ '''Reflex syncope''': induction of [[hypotension]] or [[bradycardia]] with reproduction of [[syncope]] ([[ESC#Classes of Recommendations|Class I; Level of Evidence: B]]), OR<br> ❑ '''[[Orthostatic hypotension]]''': induction of progressive [[orthostatic hypotension]] with or without symptoms ([[ESC#Classes of Recommendations|Class I; Level of Evidence: B]]) </div>}} | |||
{{familytree/end}} | {{familytree/end}} | ||
===Diagnostic | ===Diagnostic Clues=== | ||
{ | {| style="background: #FFFFFF;" | ||
| valign=top | | |||
{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;" | |||
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center colspan="3"| {{fontcolor|#FFF|Diagnostic clues for the etiologies of syncope}} | |||
|- | |||
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=left | '''''Cardiovascular syncope'''''|| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=left|'''''Orthostatic hypotension'''''|| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=left|'''''Reflex syncope''''' | |||
|- | |||
| style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left | '''Diagnostic criteria'''<br> | |||
❑ [[Arrhythmia]] and cardiac ischemia-related [[syncope]] diagnosed by [[ECG]] specific findings ([[ESC#Classes of Recommendations|Class I; Level of Evidence: C]]) <br> | |||
❑ Cardiovascular syncope due [[structural heart disease]] ([[ESC#Classes of Recommendations|Class I; Level of Evidence: C]])<br> | |||
---- | |||
'''Additional findings'''<br> | |||
❑ Presence of definitive structural hearth disease | |||
: ❑ [[Aortic stenosis]] | |||
: ❑ [[Acute myocardial infarction]] | |||
: ❑ [[Hypertrophic cardiomyopathy]] | |||
: ❑ [[Pericardial disease]] | |||
: ❑ [[Cardiac tumors]] | |||
❑ Family history of unexplained sudden death <br> ❑ Syncope during exertion or supine <br> ❑ Abnormal [[ECG]] findings<br> ❑ Sudden onset of [[palpitations]] before syncope <br> | |||
---- | |||
'''Abnormal [[ECG]] findings'''<br><div class="mw-collapsible-content"> <div class="mw-collapsible mw-collapsed"> | |||
: ❑ [[Second degree AV block classification|Mobitz I second degree AV block]] <br> [[File:Wenckebach2.png|200px]] | |||
: ❑ Non-sustained VT <br>[[File:Non-sustained VT.png|200px]] | |||
: ❑ Premature QRS complexes <br>[[File:VPC 1.png|200px]] | |||
: ❑ [[Wide QRS]](≥ 0.12 s) | |||
: ❑ Long or short [[QT interval]]s <br>[[File:LQTS.png|200px]] | |||
: ❑ Early repolarization <br>[[File:Benign early repolarization.jpg|200px]] | |||
: ❑ [[Q waves]] ([[myocardial infarction]])<br> [[File:Q wave.jpg|200px]] | |||
: ❑ Bifascicular block <br>[[File:Bifascicular block ECG.png|200px]] | |||
| style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left|'''Diagnostic criteria'''<br> | |||
❑ Syncope after standing up and documentation of [[orthostatic hypotension]] ([[ESC#Classes of Recommendations|Class I; Level of Evidence: C]]) | |||
---- | |||
'''Additional findings''' <br> ❑ Syncope after prolonged standing <br> ❑ New [[antihypertensive]] drug or dosage change <br> ❑ Presence of [[autonomic neuropathy]] <br> ❑ Prolonged standing <br> ❑ Associated with crowd or hot spaces </div> </div> | |||
| style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left|'''Diagnostic criteria'''<br> | |||
❑ [[Vasovagal syncope]] precipitated by emotional distress and is associated with typical prodome ([[ESC#Classes of Recommendations|Class I; Level of Evidence: C]]) <br> | |||
❑ Situational [[syncope]] during or after specific [[Vasovagal syncope#Triggers|triggers]] ([[ESC#Classes of Recommendations|Class I; Level of Evidence: C]])<br> | |||
❑ [[Carotid sinus hypersensitivity]] if syncope is reproduced in the presence of [[asystole]] > 3 sec and/or fall in systolic blood pressure > 50 mmHg ([[ESC#Classes of Recommendations|Class I; Level of Evidence: B]]) | |||
---- | |||
'''Additional findings''' <br> | |||
❑ Absence of heart disease <br> ❑ History of recurrent [[syncope]] <br> ❑ After unpleasant [[sight]], [[smell]], [[sound]] or [[pain]] <br> ❑ Associated to [[nausea]] or [[vomit]] <br> ❑ Prolonged standing <br> ❑ Associated with crowd or hot spaces <br> ❑ Head rotation or pressure to [[carotid sinus]]<br> ❑ After exertion <br> ❑ Postprandial | |||
|} | |||
|} | |||
<br> | |||
==Treatment== | |||
Shown below is an algorithm summarizing the therapeutic approach to [[syncope]] based on the 2009 ESC Guidelines for the Diagnosis and Management of Syncope<ref name="pmid19713422">{{cite journal| author=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.| title=Guidelines for the diagnosis and management of syncope (version 2009). | journal=Eur Heart J | year= 2009 | volume= 30 | issue= 21 | pages= 2631-71 | pmid=19713422 | doi=10.1093/eurheartj/ehp298 | pmc=PMC3295536 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19713422 }} </ref> and the 2006 AHA/ACCF Scientific Statement on the Evaluation of Syncope.<ref name="Strickberger2006">{{cite journal|last1=Strickberger|first1=S. A.|title=AHA/ACCF Scientific Statement on the Evaluation of Syncope: From the American Heart Association Councils on Clinical Cardiology, Cardiovascular Nursing, Cardiovascular Disease in the Young, and Stroke, and the Quality of Care and Outcomes Research Interdisciplinary Working Group; and the American College of Cardiology Foundation: In Collaboration With the Heart Rhythm Society: Endorsed by the American Autonomic Society|journal=Circulation|volume=113|issue=2|year=2006|pages=316–327|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.105.170274}}</ref> | |||
<span style="font-size:85%">'''Abbreviations:''' '''AF:''' Atrial fibrillation; '''SVT:''' Supraventricular tachycardia; '''VT:''' Ventricular tachycardia; '''MI:''' Myocardial infarction; '''BBB:''' Bundle branch block. </span> | |||
{{familytree/start}} | |||
{{familytree | | | | | A00 | | | | | | A00= '''Determine the etiology'''}} | |||
{{familytree | |,|-|-|-|+|-|-|-|.| |}} | |||
{{familytree | A01 | | A02 | | A03 | A01= '''Cardiovascular syncope'''| A02= '''Reflex Syncope'''| A03= '''[[Orthostatic hypotension]]'''}} | |||
{{familytree | |!| | | |!| | | |!| | }} | |||
{{familytree | D01 | | D02 | | D03 | | | D03= <div style="float: left; text-align: left; width: 24em"> ❑ Explain the diagnosis and provide reassurance ([[ESC#Classes of Recommendations|Class I; Level of Evidence: C]])<br> ❑ Explain the risk of recurrence and educate regarding avoidance of [[Vasovagal syncope#Triggers|triggers]] ([[ESC#Classes of Recommendations|Class I; Level of Evidence: C]]) <br> ❑ Educate patients with prodrome about isometric physical counterpressure maneuvers (PCM) ([[ESC#Classes of Recommendations|Class I; Level of Evidence: B]]): | |||
: ❑ Hand grip and arm tensing | |||
: ❑ Leg crossing <br> | |||
❑ Consider [[cardiac pacing]] in: | |||
: ❑ Dominant cardioinhibitory [[carotid sinus syndrome]] ([[ESC#Classes of Recommendations|Class IIa; Level of Evidence: B]]) | |||
: ❑ Recurrent reflex syncope, age >40 years and spontaneous cardioinhibitory response during monitoring ([[ESC#Classes of Recommendations|Class IIa; Level of Evidence: B]])</div> | |||
| D02= <div style="float: left; text-align: left; width: 24em"> ❑ Provide adequate hydration and salt intake ([[ESC#Classes of Recommendations|Class I; Level of Evidence: C]])<br> ❑ Provide additional therapy if needed: | |||
: ❑ Administer [[midodrine]] 10 mg PO every 8 hours ([[ESC#Classes of Recommendations|Class IIa; Level of Evidence: B]]) | |||
<span style="font-size:85%;color:red">Contraindicated in severe heart disease, acute renal failure, pheochromocytoma, severe hypertension or thyrotoxicosis </span> <br>OR<br> | |||
: ❑ Administer [[fludrocortisone]]''' 0.1 mg/day PO ([[ESC#Classes of Recommendations|Class IIa; Level of Evidence: C]]) <br> | |||
❑ Educate patients about isometric physical counterpressure maneuvers (PCM) ([[ESC#Classes of Recommendations|Class IIb; Level of Evidence: C]]) <br> ❑ Position the patient in a head-up tilt sleeping position (>10°) to increase fluid volume ([[ESC#Classes of Recommendations|Class IIb; Level of Evidence: C]]) </div> | D01=<div style="float: left; text-align: left; width: 24em; padding:1em;"> ❑ Treat the [[arrhythmia]] according to the type <br> | |||
❑ Schedule for [[cardiac pacing]] surgery in patients with: | |||
: ❑ [[Sinus node disease]] ([[ESC#Classes of Recommendations|Class I; Level of Evidence: C]]) | |||
: ❑ [[Second degree AV block classification|Mobitz II AV block]] or [[complete AV block]] ([[ESC#Classes of Recommendations|Class I; Level of Evidence: B]]) | |||
: ❑ [[BBB]] with positive [[electrophysiological study]] ([[ESC#Classes of Recommendations|Class I; Level of Evidence: B]]) <br> | |||
❑ Schedule for [[catheter ablation]] in patients with: | |||
: ❑ [[SVT]] ([[ESC#Classes of Recommendations|Class I; Level of Evidence: C]]) | |||
: ❑ [[VT]] ([[ESC#Classes of Recommendations|Class I; Level of Evidence: C]]) | |||
: ''In absence of [[structural hearth disease]]'' <br> | |||
❑ Administer [[atrial fibrillation resident survival guide#Maintenance of Sinus Rhythm|antiarrhythmic drug therapy]] in patients with: | |||
: ❑ [[AF]] ([[ESC#Classes of Recommendations|Class IIa; Level of Evidence: C]]) | |||
: ❑ Failed [[catheter ablation]] ([[ESC#Classes of Recommendations|Class I; Level of Evidence: C]])<br> | |||
❑ Schedule for [[implantable cardioverter defibrillator]] surgery in patients with: | |||
: ❑ [[VT]] with [[heart disease]] ([[ESC#Classes of Recommendations|Class I; Level of Evidence: B]]) | |||
: ❑ Electrophysiological study induced [[VT]] with previous [[MI]] ([[ESC#Classes of Recommendations|Class I; Level of Evidence: B]]) | |||
: ❑ [[VT]] with inherited [[cardiomyopathy]] or [[channelopathy]] ([[ESC#Classes of Recommendations|Class IIa; Level of Evidence: B]])</div>}} | |||
{{familytree/end}} | |||
==Do's== | ==Do's== | ||
* Consider a [[tilt test]]: | |||
** To differentiate between reflex [[syncope]] and [[orthostatic hypotension]] ([[ESC#Classes of Recommendations|Class IIa; Level of Evidence: C]]) | |||
** If syncope is due to a [[psychiatric disease]] ([[ESC#Classes of Recommendations|Class IIb; Level of Evidence: C]]) | |||
** To differenciate [[syncope]] with jerking movements from [[epilepsy]] ([[ESC#Classes of Recommendations|Class IIb; Level of Evidence: C]]) | |||
** If [[syncope]] happened after standing up from a seated position due to possible [[orthostatic hypotension]]([[ESC#Classes of Recommendations|Class IIb; Level of Evidence: C]]) | |||
* Consider implantable loop recorder before [[cardiac pacing]] in patients with suspected or confirmed reflex [[syncope]] presenting with frequent or traumatic syncopal episodes. | |||
* Perform exercise testing in patients who experience syncope during or after exertion ([[ESC#Classes of Recommendations|Class I; Level of Evidence: C]]). | |||
==Don'ts== | ==Don'ts== | ||
[[ | * Don't perform [[carotid sinus massage]] in patients with previous [[TIA]] or [[stroke]] within the past 3 months and in patients with [[carotid sinus]] bruits unless [[carotid sinus]] [[doppler]] studies excluded significant stenosis ([[ESC#Classes of Recommendations|Class III; Level of Evidence: C]]). | ||
* Don't perform [[tilt test|tilt testing]] for the assessment of response to treatment. ([[ESC#Classes of Recommendations|Class III; Level of Evidence: B]]). | |||
* Don't perform [[tilt test|isoproterenol tilt test]] in patients with [[ischemic heart disease]] ([[ESC#Classes of Recommendations|Class III; Level of Evidence: C]]). | |||
* Don't use [[adenosine]] [[stress test]] as a diagnostic test to select patients for [[cardiac pacing]] due to the lack of correlation with spontaneous [[syncope]] ([[ESC#Classes of Recommendations|Class III; Level of Evidence: B]]). | |||
* Don't perform [[electrophysiologic study]] if there is already indication for [[implantable cardioverter defibrillator]] in patients with [[ischemic heart disease]] with suspected [[arrhythmia|arrhythmic]] cause. | |||
* Don't perform [[electrophysiologic study]] in patients with normal [[ECG]], no [[heart disease]] and no [[palpitations]] unless non-syncopal [[LOC]] is suspected ([[ESC#Classes of Recommendations|Class III; Level of Evidence: B]]). | |||
* Don't give [[beta blockers]] for patients with reflex syncope ([[ESC#Classes of Recommendations|Class III; Level of Evidence: A]]). | |||
==References== | ==References== | ||
{{Reflist|2}} | {{Reflist|2}} | ||
[[Category:Cardiology]] | |||
[[Category:Resident survival guide]] | |||
[[Category:Up-To-Date]] | |||
[[Category:Emergency]] | |||
{{WikiDoc Help Menu}} | |||
{{WikiDoc Sources}} | |||
</div> |
Latest revision as of 19:31, 20 August 2014
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alejandro Lemor, M.D. [2]; Karol Gema Hernandez, M.D. [3]
Syncope Resident Survival Guide Microchapters |
---|
Overview |
Causes |
Classification |
FIRE |
Complete |
Treatment |
Do's |
Don'ts |
Overview
Syncope is the transient loss of consciousness (LOC) due to cerebral hypoperfusion and it is characterized by a rapid onset, a short duration and a spontaneous complete recovery. It is important to identify the cause of syncope and recognize high risk patients with structural heart disease or abnormal ECG findings. The initial management of syncope depends on the etiology of the syncope which can be either reflex, orthostatic hypotension or cardiovascular.
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
- Aortic stenosis
- Arrhythmia
- Medications (vasodilators, diuretics, antiarrhythmics, antipsychotics)
- Orthostatic hypotension
- Vagal stimulation
- Vertebrobasilar insufficiency[2]
Click here for the complete list of causes.
Classification
Syncope is classified based on the pathophysiology of the etiology.[3]
Cardiovascular Syncope
- Arrhythmias (bradycardia or tachycardia)
- Structural heart disease
- Drug-induced arrhythmia
Orthostatic Hypotension
- Primary autonomic failure (pure autonomic failure, Parkinson's disease)
- Secondary autonomic failure (diabetes, uremia)
- Drug-induced (alcohol, vasodilators, diuretics)
- Hypovolemia (hemorrhage, diarrhea)
Reflex Syncope
- Vasovagal
- Situational syncope (cough, sneeze, postprandial, post-exercise)
- Carotid sinus hypersensitivity
FIRE: Focused Initial Rapid Evaluation
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.
Boxes in the red signify that an urgent management is needed.
Abbreviations: CT: Computed tomography; DVT: Deep vein thrombosis; ECG: electrocardiogram; STEMI: ST elevation myocardial infarction
Identify cardinal findings that increase the pretest probability of syncope ❑ Loss of consciousness(LOC) of:
| |||||||||||||||||||||||||||||||||||||||
Differentiate syncope from other common similar presentations without LOC ❑ Vertigo ❑ Lightheadedness ❑ Epilepsy ❑ Hypoglycemia | |||||||||||||||||||||||||||||||||||||||
Does the patient have any of the findings that require urgent management? ❑ Tachycardia ❑ Hypotension ❑ Severe dyspnea ❑ Hemorrhage ❑ Seizures | |||||||||||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||||||||||
ECG findings | |||||||||||||||||||||||||||||||||||||||
Normal ECG | |||||||||||||||||||||||||||||||||||||||
Administer: ❑ Aspirin 162-325 mg ❑ Oxygen (2-4 L/min) if satO2 <90% ❑ Beta blockers (unless contraindicated) ❑ Sublingual nitroglycerin 0.4 mg every 5 min for a total of 3 doses Do not delay primary angioplasty or fibrinolysis | ❑ Manage the hypovolemic state
| Suggestive signs and symptoms: ❑ Sudden onset of dyspnea and tachypnea ❑ Tachycardia ❑ Pleuritic chest pain ❑ Symptoms suggestive of DVT ❑ Positive CT pulmonary angiography | |||||||||||||||||||||||||||||||||||||
Complete Diagnostic Approach
A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.[3][4]
Abbreviations: AF: atrial fibrillation; ARVC: arrhythmogenic right ventricular cardiomyopathy; BBB: bundle branch block; CAD: coronary artery disease; EEG: electroencephalography; HF: heart failure; MI: myocardial infarction; SCD: sudden cardiac death; SVT: supraventricular tachycardia; TIA: transient ischemic attack; VT: ventricular tachycardia
Characterize the symptoms: ❑ Loss of consciousness (LOC)
❑ Prodrome
❑ Chest pain (suggestive of cardiovascular syncope)
❑ Activity prior to LOC (suggestive of cardiovascular or reflex syncope)
| |||||||||||||||||||||||||||||||||
Inquire about medications that can cause syncope: ❑ Nitrates (decrease preload) | |||||||||||||||||||||||||||||||||
Obtain a detailed past medical history: ❑ Previous syncope episodes
❑ Cardiovascular disease
❑ Neurological diseases ❑ Metabolic disorders (diabetes) ❑ Recent trauma | |||||||||||||||||||||||||||||||||
Identify possible triggers: Suggestive of reflex syncope Suggestive of cardiovascular or orthostatic hypotension | |||||||||||||||||||||||||||||||||
Examine the patient:
Vitals
Respiratory Cardiovascular
Neurologic
❑ Glasgow coma scale
| |||||||||||||||||||||||||||||||||
Order labs and tests: ❑ EKG (most important initial test)
❑ Glucose (rule out hypoglycemia)
| |||||||||||||||||||||||||||||||||
Confirm diagnosis of syncope Must have this 3 characteristics: ❑ Short duration, AND ❑ Rapid onset, AND ❑ Complete spontaneous recovery | |||||||||||||||||||||||||||||||||
Syncope | Non-syncopal LOC | ||||||||||||||||||||||||||||||||
Known etiology | Unknown etiology | Consider additional tests ❑ Stool guaiac test (rule out GI bleeding) ❑ Blood and urine toxicology tests (rule out intoxication) | |||||||||||||||||||||||||||||||
Determine the etiology: ❑ Cardiovascular
❑ Reflex
| Determine if there are any high risk criteria: ❑ Severe structural heart disease ❑ CAD ❑ Clinical or ECG features suggesting arrhythmic syncope ❑ Important comorbidities
| Consider alternative diagnoses:
| |||||||||||||||||||||||||||||||
High risk | Low risk | ||||||||||||||||||||||||||||||||
❑ Immediate in-hospital monitoring (in bed or telemetry) to look for abnormalities suggestive of arrhythmic syncope (Class I; Level of Evidence: B) | |||||||||||||||||||||||||||||||||
Recurrent episodes of syncope ❑ Order a Holter if > 1 episode/week (Class I; Level of Evidence: B) ❑ Order external loop recorder (ELR) if interval between episodes < 4 weeks (Class IIa; Level of Evidence: B) ❑ Perform carotid sinus massage in patients > 40 years with uncertain syncopal etiology (Class I; Level of Evidence: B)
| Single episode of syncope | ||||||||||||||||||||||||||||||||
In case of suspicion of structural heart disease: ❑ Order an echocardiography (Class I; Level of Evidence: B) | Is any of the following high risk setting present? ❑ Potential risk of physical injury ❑ Occupational implications | ||||||||||||||||||||||||||||||||
Presence of structural heart disease | Absence of structural heart disease | Yes | No | ||||||||||||||||||||||||||||||
❑ Treat accordingly | Perform a tilt test (Class I; Level of Evidence: B) | No further investigation | |||||||||||||||||||||||||||||||
❑ No findings, OR ❑ Reflex syncope: induction of hypotension or bradycardia with reproduction of syncope (Class I; Level of Evidence: B), OR ❑ Orthostatic hypotension: induction of progressive orthostatic hypotension with or without symptoms (Class I; Level of Evidence: B) | |||||||||||||||||||||||||||||||||
Diagnostic Clues
|
Treatment
Shown below is an algorithm summarizing the therapeutic approach to syncope based on the 2009 ESC Guidelines for the Diagnosis and Management of Syncope[3] and the 2006 AHA/ACCF Scientific Statement on the Evaluation of Syncope.[4]
Abbreviations: AF: Atrial fibrillation; SVT: Supraventricular tachycardia; VT: Ventricular tachycardia; MI: Myocardial infarction; BBB: Bundle branch block.
Determine the etiology | |||||||||||||||||||||||||
Cardiovascular syncope | Reflex Syncope | Orthostatic hypotension | |||||||||||||||||||||||
❑ Treat the arrhythmia according to the type ❑ Schedule for cardiac pacing surgery in patients with:
❑ Schedule for catheter ablation in patients with:
❑ Administer antiarrhythmic drug therapy in patients with: ❑ Schedule for implantable cardioverter defibrillator surgery in patients with:
| ❑ Provide adequate hydration and salt intake (Class I; Level of Evidence: C) ❑ Provide additional therapy if needed: Contraindicated in severe heart disease, acute renal failure, pheochromocytoma, severe hypertension or thyrotoxicosis
❑ Position the patient in a head-up tilt sleeping position (>10°) to increase fluid volume (Class IIb; Level of Evidence: C) | ❑ Explain the diagnosis and provide reassurance (Class I; Level of Evidence: C) ❑ Explain the risk of recurrence and educate regarding avoidance of triggers (Class I; Level of Evidence: C) ❑ Educate patients with prodrome about isometric physical counterpressure maneuvers (PCM) (Class I; Level of Evidence: B):
❑ Consider cardiac pacing in:
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Do's
- Consider a tilt test:
- To differentiate between reflex syncope and orthostatic hypotension (Class IIa; Level of Evidence: C)
- If syncope is due to a psychiatric disease (Class IIb; Level of Evidence: C)
- To differenciate syncope with jerking movements from epilepsy (Class IIb; Level of Evidence: C)
- If syncope happened after standing up from a seated position due to possible orthostatic hypotension(Class IIb; Level of Evidence: C)
- Consider implantable loop recorder before cardiac pacing in patients with suspected or confirmed reflex syncope presenting with frequent or traumatic syncopal episodes.
- Perform exercise testing in patients who experience syncope during or after exertion (Class I; Level of Evidence: C).
Don'ts
- Don't perform carotid sinus massage in patients with previous TIA or stroke within the past 3 months and in patients with carotid sinus bruits unless carotid sinus doppler studies excluded significant stenosis (Class III; Level of Evidence: C).
- Don't perform tilt testing for the assessment of response to treatment. (Class III; Level of Evidence: B).
- Don't perform isoproterenol tilt test in patients with ischemic heart disease (Class III; Level of Evidence: C).
- Don't use adenosine stress test as a diagnostic test to select patients for cardiac pacing due to the lack of correlation with spontaneous syncope (Class III; Level of Evidence: B).
- Don't perform electrophysiologic study if there is already indication for implantable cardioverter defibrillator in patients with ischemic heart disease with suspected arrhythmic cause.
- Don't perform electrophysiologic study in patients with normal ECG, no heart disease and no palpitations unless non-syncopal LOC is suspected (Class III; Level of Evidence: B).
- Don't give beta blockers for patients with reflex syncope (Class III; Level of Evidence: A).
References
- ↑ 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) - ↑ Kapoor, WN. (2000). "Syncope". N Engl J Med. 343 (25): 1856–62. doi:10.1056/NEJM200012213432507. PMID 11117979. Unknown parameter
|month=
ignored (help) - ↑ 3.0 3.1 3.2 3.3 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). - ↑ 4.0 4.1 Strickberger, S. A. (2006). "AHA/ACCF Scientific Statement on the Evaluation of Syncope: From the American Heart Association Councils on Clinical Cardiology, Cardiovascular Nursing, Cardiovascular Disease in the Young, and Stroke, and the Quality of Care and Outcomes Research Interdisciplinary Working Group; and the American College of Cardiology Foundation: In Collaboration With the Heart Rhythm Society: Endorsed by the American Autonomic Society". Circulation. 113 (2): 316–327. doi:10.1161/CIRCULATIONAHA.105.170274. ISSN 0009-7322.