Syncope From Greek meaning pause Amal Mattu Article on EKG findings to check for all syncope patients Strayer-Tainter Syncope Sheet My EKG My EKG Sheet Cardiac Causes Obstruction to flow • Subaortic stenosis • Aortic valve stenosis • Mitral valve stenosis • Atrial myxoma (rare) • Pulmonic valve stenosis • Hypertrophic cardiomyopathy • Dilated cardiomyopathy • Restrictive cardiomyopathy • Pericardial tamponade • Severe congestive heart failure Vascular disease • Pulmonary emboli • Pulmonary hypertension • Acute myocardial infarction • Air embolism • Aortic dissection/leaking aortic aneurysm • Subclavian steal syndrome Dysrhythmias Tachydysrhythmias • Supraventricular tachycardia • Ventricular tachycardia • Ventricular fibrillation • Atrial fibrillation with fast conduction • Wolff-Parkinson-White syndrome • Prolonged QT syndrome • Brugada syndrome Bradydysrhythmias • Atrioventricular block • Atrial fibrillation with slow conduction • Sick sinus syndrome • Pacemaker malfunction Noncardiac Causes Vasodepressor (vasovagal, neurocardiogenic) • Situational • Micturition • Post-tussive • Swallow • Defecation • Valsalva (weightlifters) • Carotid sinus sensitivity Orthostatic • Anemia/GI bleed • Dehydration Central nervous system / neurologic • Seizure (excluded by most syncope studies) • Neuralgias (trigeminal, glossopharyngeal) • Neurologic (TIA, strokes, migraines [rare]) • Subarachnoid hemorrhage • Subdural/epidural hemorrhage Metabolic / toxic • Hypoglycemia • Hypoxia • Drug-induced • Carbon monoxide poisoning • Chemical / toxic gas exposure • Carotid sinus sensitivity • Infectious agent Psychogenic • Somatization disorder • Anxiety disorder • Conversion disorder • Panic disorder • Hyperventilation • Breath-holding spells Causes of collapse2 Differential diagnosis Clinical clues Hypoxia, hypoglycaemia Should be picked up in primary survey Do not forget the glucose Epilepsy* Previous history, postictal period Affective (psychological) History of anxiety or panic disorder, hyperventilation Dysfunction of brain stem—for example, vertebrobasilar transient ischaemic attack, basilar migraine Cerebellar signs on neurological examination Heart—for example, ischaemic heart disease Recent chest pain, history of myocardial infarction Emboli—pulmonary embolism Pleuritic chest pain, dyspnoea, calf pain, or swelling Aortic obstruction—for example, stenosis, hypertrophic obstructive cardiomyopathy (HOCM) Precipitated by exertion, cardiac murmur on auscultation Rhythm disorders—for example, sick sinus syndrome, complete heart block May be picked up on primary survey if heart rate *Common causes In seconds preceding LOC there is a loss of lateral gaze, possibly dizziness Vascular/Cardiac-rhythmic, obstructive, metabolic, meds Vasomotor-consider AAA, ectopic, and other sources of occult bleeding Cardiac-if exercise induced, think IHSS, valvular disorder, or subclavian steal Stokes-Adams: heart block, syncope, vertigo Cough, micturition, post-prandial Place pregnant women in LLR High risk if 60 y/o or Cardiac history CHF on exam assoc.c high risk 12 Lead EKG (even in the young for prolonged QT and Brugada), consider CBC or guiac and pregnancy test.

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According to ECS guidelines, orthostatic blood pressures are recommended to be taken after five minutes of being supine.

A decrease of more than 20mm Hg in the systolic pressure is considered abnormal as is a drop in pressure below 90mm Hg independent of the development of symptoms.

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It may also occur in association with prolonged standing or kneeling in a crowded or warm place or on exertion (all three latter scenarios may also be due to autonomic failure) b.

Situational syncope occurs during or immediately after coughing, micturition, defecation or swallowing.

Syncope associated with throat or facial pain, however, may be due to glossopharyngeal or trigeminal neuralgia c.