Syncope resident survival guide

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.

• Hemorrhage
• Hypotension
• Hypoxia
• Ruptured abdominal aortic aneurysm
• Ventricular arrhythmia

Common Causes

• Arrhythmia
• Medication
• Orthostatic hypotension
• Vagal stimulation
• Vertebrobasilar insufficiency

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 ❑ TIA of carotid origin

If no to ≥1; exclude the following before proceeding with syncope evaluation: ❑ Coma ❑ Aborted SCD ❑ 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

Suspected syncope: ❑ Initial Assessment

❑ Clinical history ❑ Physical examination (including supine and standing BP measurement after 3 minutes if OH is suspected) ❑ 12 Lead EKG

Syncope

T-LOC non syncopal

Certain diagnosis of syncope: ❑ Go to Diagnostic Evaluation algorithm for management of specific type of syncope

Uncertain etiology

Confirm with specific test OR specialist

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

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

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.