Download SWOONING AND VAPORS

SWOONING AND VAPORS
Syncope and near syncope
Syncope accounts for 3% ER visits
• Syncope/pre-syncope symptoms are due to a
reduction in cerebral perfusion, most often as
result of decreased blood pressure.
Blood pressure is dependent on
• Cardiac output
• Vascular tone
• Vascular volume
Cardiac output
• HEART RATE: too slow/fast, arrhythmias
• MECHANICAL: aortic/mitral stenosis;
pulmonary emboli; HOCUM; Cardiomyopathy
VASCULAR VOLUME
• Blood loss
• dehydration
VASCULAR TONE
•
•
•
•
•
Drugs
Neuromediated
Autonomic insuffiency
Orthostasis
Vascular disease-carotid, vertebralbasilar
CAUSES OF SYNCOPE
•
•
•
•
•
•
Cardiac: 14% arrhythmia/ 4% mechanical
Neurologic: 10%
Neurally mediated: Vasovagal 18-25%
Orthostatic: 8-10%
Psychiatric: 2%
No clear etiology 33-45%
PROGNOSIS VARIES WITH ETIOLOGY
• Cardiac syncope
– 25% 1 year mortality
– 14% 1 year CSD
Non-cardiac syncope
-7% 1 year mortality
-3% 1 year CSD
HISTORY AND PHYSICAL
• More than 50% of diagnosis should come from
History and Physical
•
•
•
•
•
•
Prior incidence?
Behavior at time of event
Symptoms prodrome?
Duration of LOC?
Mental status afterwards
Witness information?
BEHAVIOR/CONDITIONS
Postural change
Cough
Swallowing
Head turning/neck pressure
Defecation
Pain
Strong emotion
Prolonged standing
At rest or with activity
Tremor seizure activity
Symptoms
•
•
•
•
•
•
•
•
Nausea
Pallor
Warmth/flushed
Diaphoresis
Palpitations
Visual/hearing changes
Confusion
headache
• Duration of LOC/event seconds-hours
• Mental status after postictal/washed out
• Witness information
Past medical History
•
•
•
•
•
Structural heart disease
Previous heart rhythm problems
Seizure history
Vascular disease
Drugs and recent changes
PHYSICAL EXAM
• Vital signs, including orthostatic blood
pressures->20 mmHg drop in BP with standing
• Carotid hypersensitivity>3 sec pause, 50
mmHg asymptomatic or 30 mmHg
symptomatic BP drop (up to 5 sec massage)
• Bruits
• Murmur
• Neurological findings
diagnostics
• ECG 5% unselected diagnostic yield
– Long QT; afib/flutter; MAT; paced; VPB; V tach;
bundle branch block; LVH; Old MI;WPW; Mobitiz
type II
– ECHO: 5-10 %unselected diagnostic yield
– EST: activity associated symptoms
– Monitor holter/event monitor
– Tilt table test
NEUROCARDIOGENIC SYNCOPE
• Very common 20-25% in most series
• Usually manifests by second decade of life
• Abnormal reflex-mediated
– Usually upright position
– Trigger/prodrome
– Decreased venous return; increased LV
contractility; mechanical receptor activation—
leads to—vasodilatation/bradycardia—manifests
as hypotension-syncope
SYCOPE DIAGNOSIS SCORING SYSTEM
• PATIENT FEATURE
• Female, <42 yrs
• Syncope/presyncope
–
–
–
–
–
–
–
–
–
–
–
–
POINTS
7
Headache/flushing/pain
3 for each
Nausea
2
Diaphoresis
2
Male <43 yrs
2
Prolonged orthostasis
1
Cyanosis
-4
Diabetes
-4
Bifasicular block
-3
Chest pain with fainting
-2
Postictal confusion
-1
Memory of fainting
-1
Score 3 or > vasovagal syncope; score 2 or less another source
NEUROCARDIOGENIC SYNCOPE
• Triggers: pain; strong emotion/stress;
prolonged standing
• Situational: micturation; defication; cough;
deglutation
PREDICTORS OF POOR OUTCOME IN
SYNCOPE PATIENTS
• Abnormal ECG-non-specific ST or sinus
tachycardia
• Prior ventricular arrhythmia >10VPB/hr; VPB
pairs; multifocal VPB
• CHF history
• Age >45 years (without prior history of syncope)
• If 0
5% 1year arrhythmia/death
• If 1
10%
• If 3-4
60%
WHEN TO HOSPITALIZE
•
•
•
•
•
History of chest pain
Hx of CAD, CHF, Ventricular ectopy
Evidence of CHF,AS, focal neuro defect
ECG abnl.-BBB; ischemia; MI;arrhythmia
Consider-for exertional syncope; frequent
spells; age >70 yr; orthostasis; sustained
physical injury; suspected ACS