Syncope
MUDr. Anna Hasara, ARK FNUSA
MUDr. Lukáš Dadák
Learning objectives:
̶ Student will learn the most common causes of syncope.
̶ Student will learn the FA to a casualty with a syncope.
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Introduction
̶ Syncope is a clinical syndrome in which transient loss of
consciousness (TLOC) is caused by a period of inadequate
cerebral blood flow, most often the result of an abrupt drop of
systemic blood pressure
̶ Brief duration (8 to 10 seconds)
̶ By definition spontaneously self-limited
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Epidemiology
̶ Prevalence in the population of approximately 20%
̶ Only 1 % needs hospital admission
̶ Incidence of syncope is roughly bimodal
- in late adolescence to early adulthood
- in older age, with a sharp rise after age 70 years
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Reflex-related Ortostatic Cardiac
https://www.syncopedia.org/cases-examples/
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Causes
Reflex-mediated Orthostatic hypotension Cardiac
1. Vasovagal
- Orthostatic vasovagal syncope:
usually after prolonged standing,
frequently in a warm environment,
etc
- Emotional vasovagal syncope:
secondary to fear, pain, medical
procedure, etc
- Unknown trigger
1. Medication-related
- Diuretics (eg, thiazide or loop
diuretics)
- Vasodilators (eg,
dihydropyridine calcium channel
blockers, nitrates, alpha
blockers, etc)
- Antidepressants (eg, tricyclic
drugs, SSRIs, etc)
1. Tachyarrhythmias
- Ventricular tachycardia
- Supraventricular tachycardias
2. Situational
- Micturition, defecation
- Swallowing
- Coughing/sneezing
2. Volume depletion
- Hemorrhage
- Gastrointestinal losses (ie,
vomiting or diarrhea)
- Diminished thirst drive
(primarily in older patients)
2. Structural disease
- Severe aortic stenosis
- Hypertrophic cardiomyopathy
- Cardiac tamponade
- Prosthetic valve dysfunction
3. Carotid sinus syndrome 3. Autonomic failure
Primary: pure autonomic failure,
Parkinson’s disease, multiple
system atrophy, Lewy body
dementia
Secondary: diabetes mellitus,
amyloidosis, spinal cord injuries,
autoimmune neuropathy (eg,
Guillain-Barré), paraneoplastic
neuropathy
3. Cardiopulmonary /vascular
- Pulmonary embolus
- Severe pulmonary hypertension
- Aortic dissection
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Clinical symptoms
1. Prodromal symptoms
̶ Lightheadedness
̶ A feeling of being warm or cold
̶ Sweating
̶ Palpitations
̶ Nausea or nonspecific abdominal discomfort
̶ Visual "blurring" occasionally proceeding to temporary darkening or "white-out" of vision
̶ Diminution of hearing and/or occurrence of unusual sounds
(particularly a "whooshing" noise)
̶ Pallor reported by onlookers
2. Transient loss of consciousnes(! CAVE trauma!)
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First aid
1. Identification and treatment of prodromal symptoms
2. Immediate treatment of syncopal patients
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Identification and treatment of prodromal symptoms
- Avoiding hazards
(pulling off to the side of road if driving or lying down to avoid a
fall)
- Respond to the warning by finding a safe location
(seated or ideally supine)
- Physical isometric counterpressure maneuvers:
- leg-crossing
- lower body muscle tensing
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Isometric Counterpressure Maneuvers
• Sit down and tilt head forward
• Squat
• Leg-crossing
https://onlinelibrary.wiley.com/doi/full/10.1111/joim.12249
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Treatment of syncopal patients
Safety
1. Assist the patient to the ground, chair, or stretcher to avoid traumatic injury. When necessary, remove the patient
from any potential external dangers (eg, high places, water, electrical wires, etc).
2. Lay the patient supine.
Stimulate (Unresponsive à Alert)
3. Attempt to arouse the patient. Do not try to raise the patient up until the patient indicates readiness to do so. Raising
the patient too soon may trigger recurrent transient loss of consciousness
Shout for help
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Treatment of syncopal patients
Airways (usually patent and open)
Breathing (normal breathing)
Circulation (puls is pressent)
elevate legs if possible to enhance venous return to the heart and thereby restore adequate
cerebral perfusion)
• Observe for other signs (pallor, diaphoresis, seizure activity) that may assist in establishing
the etiology.
• Obtain medical history to identify cause of syncope.
• Give fluids (only fully consciousness casualty).
http://exfau.tripod.com/firstaid/blood_circulation_system.html
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When to call emergency (155/112)
• Not normal consciousness > 5 minutes
• Possibility of cardiac cause of syncope
- syncope while sitting, lying, effort syncope
- „cardiac prodroms“- palpitation, breathlessness, chest pain ...
- previous medical history of cardial problems (heart attack, arythmias,...)
• Trauma as a result of syncope and fall
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Video of syncopal patients
• https://www.syncopedia.org/aiovg_videos/orthostatic-vasovagal-syncope/
• https://www.syncopedia.org/aiovg_videos/post-exercise-vasovagal-syncope/
Learning outcomes:
• Student is able to list the most frequent reasons of syncope.
• Student is able to list the most frequent symptoms of syncope.
• Student is able to administer first aid to a casualty with a syncope.
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Literature
• https://www.uptodate.com/contents/syncope-in-adults-clinical-
manifestations-and-initial-diagnostic-evaluation
• https://www.syncopedia.org/
• https://www.syncopedia.org/video-library/
Simulation Centre, Faculty of Medicine, Masaryk University
2020