Syncope

Syncope

Feb 10, 2015 0
cardiology,emergency,onthepods
Script Writer:  Abhijit Pal
Summary Writer:  Abhijit Pal
Editor:  James Edwards
Interviewee:  Belinda Gray

James talks to Dr Belinda Gray, Cardiologist, about syncope on the wards.

About Dr Belinda Gray

Belinda is currently an NHMRC Neil Hamilton Fairley Early Career Fellow at St George’s, University of London, in Sports Cardiology and Inherited Cardiac Conditions with Professor Elijah Behr and Professor Sanjay Sharma. Belinda’s research focuses on risk stratification, genetics and prevention of sudden cardiac death in the young, including young athletes. Belinda graduated in medicine from the University of NSW in 2006 and completed her PhD at the University of Sydney in 2016 with the support of a Heart Foundation PhD Scholarship.

She is a module lead and lecturer in the Masters of Sports Cardiology (MSc) at St George’s, University of London. Belinda has received numerous research grants and has presented at national and international conferences including the Young Investigator Awards at the Heart Rhythm Society Annual Scientific meeting in USA, and the Ralph Reader Prize at the Cardiac Society of Australia and New Zealand. She is an early career researcher with more than 30 peer-reviewed publications.

Syncope

With Dr. Belinda Gray, Cardiology Advanced Trainee at Royal Prince Alfred Hospital, New South Wales, Australia.

Case

You’ve been called to see a patient who has lost consciousness but now seems alert.

  • Is the patient conscious? If not conscious – call cardiac arrest.
  • What are the patient’s vitals? HR? BP?
  • Ask for an ECG, BSL.
  • Important to clarify if this was in fact a syncopal episode:
    • A sudden, spontaneous LOC, with associated loss of posture and tone from which the recovery is also spontaneous.
  • Major injury/head injury due to rapid LOC?
  • Neurocardiogenic (vasovagal)
    • Diagnosed on history
  • Cardiac arrhythmias
    • Tachyarrhythmias
    • Bradyarrhythmias
    • Structural (PE, AS, heart failure)
  • Orthostatic hypotension (Parkinson’s, autonomic neuropathy), volume depletion, diarrhoea/vomiting, dehydration.
  • Other causes (e.g. neurological) – are rare (e.g. seizures, strokes, metabolic causes, psychological causes).
  •  History:
    • Clarify the events leading up to syncopal episode.
    • Feeling unwell prior? Palpitations? Chest pain?
    • Any circumstances leading to the event? Seizure like activity? (Be careful, it doesn’t exclude cardiac causes.) During micturition? During defecation? During a painful episode? Psychosomatic (think of this last)?
    • History of syncopal episodes, particularly with standing? More concerning if no history.
    • Did the patient sustain a major injury? A loss of cardiac output does not allow for preparation. Often patients with primary cardiac cause have sustained a significant injury.
    • Incontinent or confused afterwards? More likely seizure.
    • Weakness in limb? Can be a stroke.
    • Massive haemorrhage in post surgical situations.
    • High dose of medications (e.g. beta blockers).
    • Known structural heart disease – risk of VT.
    • Recent long trip or malignancy – risk of PE.
    • Implanted device (PPM or AICD? Malfunction).
  • Examination:
    • Postural BP
    • Murmur (particularly AS or LVOT – eg. HOCM or elderly patients with LVH)
    • Volume status
    • Brief neurological examination (ensure no signs of stroke or TIA)
    • BSL
    • Ensure no complication from syncope (e.g. head injury or laceration).
  • ECG (rate, rhythm – PR interval, QRS duration, QT interval, bundle branch block? ST elevation, particularly left main disease can present with syncope, sinus tachycardia – PE, delta waves in a young patient WPW).
  • IVC, FBC, EUC, BSL, ABG (quick Hb).
  • Review their telemetry if they are on a monitor and look for correlating events.
  • Echocardiogram.
  • Holter monitor.
  • CT brain if any neurological signs.
  • CTPA if PE suspected.
  • EEG if seizure.
  • Device interrogation (if PPM or AICD in place).
  • Implantable loop recorder later to capture events.
  • If no precipitant identified (e.g. anaemia, standing quickly, volume loss, painful stimulus) and sustained injury.
  • Any symptoms prior to syncopal episodes e.g. chest pain or palpitations.
  • Dyspnoea.
  • If after hours and concerned, call the medical registrar and then evaluate and organise 24 hours of monitoring if required.
  • Address all reversible causes (hypoglycaemica, hypotension due to volume depletion or haemorrhage, or clear precipitant like STEMI or PE).
  • Neurological causes of syncope are rare.
  • Almost always cardiac or neuro-cardiogenic.
  • Important to differentiate between the two.
  • The ECG is the most important test. Repeat the ECG if worried.

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Tags: #Cardiac arrhythmias,#cardiology,#ECG,#fainting,#loss of consciousness,#syncopal episode,#Syncope

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