CLINICAL MANAGEMENT GUIDELINE

Syncope

ICD10: Syncope and collapse [R55]

Treatment: ER general approach

Definition:

Syncope is a transient loss of consciousness ("blackout") and quick recovery (1). It may be associated with sudden muscle weakness and falls.

It associated with loss of postural tone, followed by recovery with no need for invasive intervention.

Pathophysiology:

Sudden global hypoperfusion to the cerebrum and/or focal to the reticular activation system.

DDx: (2), (3)

RiskFrqDiagnosisUnique clinical findingsInvestigations
CommonVasovagal• Common in elderly. > Trigger: sight of blood, strong emotion, sudden abdo pressure; cough, defication
🚩CommonArrhythmias; tachy /brady> Bimodal age distribution. > Hx of cardiac pathology; ACS, valve, >> Beta or CC blocker ,amiodarone > Palpitation, lightheadedness, dyspneaECG; tachy/brady, LBBB, QT prolongation, delta wave. Echo; to exclude clot.
🚩CommonACS> Elderly w/ ACS risks. > Anginal pain. > maybe S3,S4,⇧JVP,CHF signsECG; ST elevation/depressed, old deep Q. BNP, Troponin.
🚩UnCommonCardiac Structural:> Elderly. > dyspnea, angina, dizziness, CHF signs. > may be systolic or diastolic murmurs, ⇧JVPEcho; tamponade/effusion, valves stenosis, hypertrophic heart, +/- HFrEF, myxoma. ECG: low voltage QRS, ST changes
🚩CommonMyocardial pathology> Elderly. > CHF. > systemic infection or autoimmune?ECG, BNP
🚩CommonHypovolemia> ⇧HR, ⇩BP. > BP supine and standing is > 20 mmHg > Acute tearing back pain; AAA.⇧ Blood urea, creatinine, Na๋, Abdo/thorasic CT/US/TEE, ⇩Hb,
🚩CommonGasto bleeding> Hx Coagulopathy or Iatrogenic; meds. > GIT severe ulcer w/ haematemesis, melaena. > ⇧HR, ⇩BP, Abdo. tender w/ ⇩ bowl mov.⇩Hb, ⇧ Blood urea, creatinine, Na๋, Endoscope/colonoscope
🚩UncommonAcute massive PE> Dyspnea, pleuritic pain, > Risk of hypercoagulability; immobilized, OCP, malignancy. > ⇧HR, ⇧RR, ⇩BP, ⇧JVP, Rt Vent. lift.ECG, D-dimer, CXR, CT Pul Angio, V/Q scan, atrial gases
🚩UncommonEctopic pregnancy> amenorrhea; missed period, Hx, or risk factors of ectopic preg. > Vaginal bleeding, ⇧HR, ⇩BP, Abdo. tender w/ ⇩ bowel mov.+ve hCG, ⇩ Hb.
🚩UnCommonHypoGlycemia> Uncontoll diabetis, Meds induced > tremor, sweating.Blood glucose, sulphonyurea level
🚩UnCommonAddison disease> nausea/vomiting, fatigue, salt craving, > co-exisiting autoimmune. > ⇩BP, skin hyperpigmentation⇩Na,⇧K, ⇩ morning cortisol (<3 µg/dL), ⇩ cortisol response (<18 µg/dL)to stimulation test, Abdo CT; adrenal glands swell/calcificatio.
🚩UncommonTIA/ stroke; vertbrobasilar> Motor deficit; nystagmus, ataxia. > Sensory deficit; contraLateral pain & temp sensory loss; IpsiLateral taste loss and extremities numbness.Brain MRI, CT, carotid doppler
UncommonPanic attack> Hx of anxiety, no known trigger. > at episode: fear of death, pounding heart, SOB, hot flashes, chest pain.
UncommonCarotid sinus hypersensitivty> Triggered by shaving. > Common in elderly patients.
-Post-exercise, postprandial
CommonOrthostatic hypotention> common in elderly patinets.
CommonMedication-induced> Ca Channel, beta, alpha-blockers, nitrates, antiarrythmics, diuretics, antispycotics, antiemitics.

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