today I'll be discussing the approach to Syncopy first let's define it it has four components an Abrupt transient loss of consciousness loss of postural tone meaning if someone is standing they fall to the ground and if they are sitting they slump down into their seat it is of short duration and the person experiences a spontaneous recovery in addition Syncopy may be associated with a prodrome including lightheadedness nausea diaphoresis and visual disturbances that can precede the loss of consciousness for several seconds to several minutes the occurrence of a prodrome without a subsequent loss of consciousness is referred to as pre Syncopy Syncopy PR Syncopy and isolated transient Li headedness all exist on a spectrum and have the same ideologies and all of those ideologies have the same common pathophysiological Endo they cause a transient GL reduction in blood flow to the brain due to either brief hypotension and or bra cardia a diagnostic framework for Syncopy can divide ideologies into three primary mechanisms reflex cardiogenic and orthostatic reflex Syncopy is a heterogeneous collection of ideologies in which Syncopy occurs as a result of A Dysfunctional response of the autonomic nervous system to normal stimuli the precise mechanism of most of these ideologies is not well understood there are three clinical subtypes of reflex Syncopy the first is called Vaso vagal Syncopy and it's the overall most common cause of Syncopy Vaso vagal events can occur on account of prolonged standing emotional stress or blood draw it can also be triggered by severe pain particularly intraabdominal pain a second clinical subtype is situational Syncopy which is when a specific normal phys physiologic action recurrently triggers an event this can be coughing sneezing urination known in this context as mition defecation or post exercise the last clinical subtype under reflex Syncopy is corroded sinus hypers sensitivity this is when a person's Barrel receptor reflex mediated by the cored sinus near the bifurcation of the cored artery responds too vigorously to brief increases in blood pressure to the point that external pressure applied to the CED sinus results in either Vaso dilation and or bra cardia confusingly the term basil vagal Syncopy is also frequently used as a synonym for reflex Syncopy encompassing its other clinical subtypes cardiogenic Syncopy is a category which includes all ideologies that arise from within the heart these include both Brady arhythmia and Tachi arhythmia although the only Tachi arhythmia that commonly causes syncopy is ventricular tacac cardia most other Tachi arhythmia typically present with palpitations instead cardiogenic Syncopy also includes mechanical ideologies such as aortic stenosis and hypertropic cardiomyopathy and includes the miscellaneous ideology of massive pulmonary embolism the last major mechanism in our framework is orthostatic hypotention this is a situation in which a patient's blood pressure drops precipitously upon standing it is arbitrarily defined as the presence of either a systolic drop of 20 mm of mercury or a diastolic drop of 10 mm of mercury when moving from the lying to standing position orthostatic hypotension can be subdivided into volume depletion from any cause medication side effects in which alpha blockers anti-depressants and anticho are the most commonly implicated and autonomic failure as seen with Parkinson's disease diabetes and alcoholism along with many other conditions in addition to our three main mechanistic categories there is one final category for Syncopy mimics these are conditions which can look like Syncopy but are not the most notable one here is seizure which I'll discuss more in a minute vertebral Basler insufficiency occurs when atherosclerosis of the vertebral Basler arterial system causes transient esea of the brain stem subclavian steel syndrome occurs when atherosclerosis or or clot in one of the subclavian arteries proximal to the takeoff of a vertebral artery leads to the reversal of flow in that vertial artery which then shunts blood away from the basil artery together vertibo basil insufficiency and subclavian steel syndrome are sometimes referred to as cerebrovascular Syncopy it's semantics as to whether these represent true Syncopy or our Syncopy mimics references appear to be split on the issue but they are both rare and should only be considered once other diagnoses have been ruled out an alcohol blackout can be mistaken for Syncopy particularly if the event was unwitnessed many medications can cause sedation as a side effect which occasionally can result in a seemingly abrupt loss of consciousness while an individual is sitting quietly particularly in the elderly and finally there's an entity known as psychogenic pseudos Syncopy which is a primary psychiatric issue and typically a form of conversion disorder unfortunately psychogenic pseudos Syncopy is really hard to diagnose and is particularly hard to distinguish from vasil vagal Syncopy I'll now talk about the assessment of an individual patient presenting with possible Syncopy where do we start the most important questions to ask a patient who has syncopized are what were you doing immediately before you passed out did you have any symptoms immediately preceding it that is was there a prodrome did you injure yourself in the fall do you know how long you were unconscious for when you awoke how long did it take for you to feel more or less back to normal and was the event witnessed by anyone because the patient themselves cannot be relied on for an accurate answer to those last two questions we'll now incorporate this information into our diagnostic algorithm the first step in the algorithm is to consider the duration of loss of consciousness loss of consciousness in Syncopy lasts for seconds to know more than about 5 minutes if the person was completely unconscious for longer than this it probably wasn't Syncopy instead consider a medication side effect alcohol blackout drug intoxication concussion narcolepsy or hypersomnolence related to obstructive sleep apnea which on occasion really can be that dramatic once you determine that the loss of consciousness was transient then you must differentiate Syncopy from seizure there are three main relevant questions to do this did the patient have tonic clonic movements during the loss of consciousness this is not always as straightforward as it might seem since patients with Syncopy can experience non-epileptic mild clonic jerks that can look rhythmic and it's very common for bystanders even Healthcare professionals to mistake such movements for seizure activity second was there bladder or bowel incontinence Bladder incontinence is common but not Universal with the seizure but can also uncommonly happen with the Syncopy bow incontinence is a little bit less common with the seizure but does not happen with Syncopy and third how long was the patient confused for once Consciousness was regained patients with Syncopy would usually be confused only for seconds to a couple of minutes whereas patients who have suffered a seizure usually take more than a few minutes for the confusion to fully resolve none of these three questions will make a black or white distinction between Syncopy or seizure and there will be patients that won't clearly have one or the other after your history however as a general rule patients who have witnessed tonic clonic movements bladder plus or minus bound Inc continents and prolonged confusion after the event likely had a seizure and if there were either no tonac clonic movements or just a few non-rhythmic J jks no incontinence and brief post-event confusion the patient likely had Syncopy also as a very general rule Syncopy is more common than seizure in adults who do not already have a diagnosis of a seizure disorder if you feel like Syncopy is the most likely diagnosis now is the time to consider which general mechanistic category the patient falls into based upon a few key historical questions the patient's past medical history a focused physical exam and their ECG this is particularly important because cardiogenic Syncopy suggests the possibility of life-threatening underlying pathology whereas the only risks from reflex and orthostatic Syncopy are trauma related to Falls during the events I'll discuss reflex Syncopy first reflex Syncopy is usually precipitated by a clearly identifiable trigger It's associated with a prod Drome and that advanced warning of an impending loss of consciousness is usually enough to prevent significant injury during the fall patients tend to be younger and there are no notable risk factors exam is usually normal as is the ECG if the vasovagal or situational subtypes of reflex Syncopy are suspected additional testing is usually unnecessary but an amatory ECG monitor can be considered particularly if events are recurrent and relatively frequent kateed hypers sensitivity can be confirmed by crowded sinus massage cardiogenic Syncopy usually has either no precipitant or is precipitated by exertion a pro drone May either be present or absent an injury during the fall is common particularly during events not preceded by a prod drone patients affected by cardiogenic Syncopy tend to be older and have risk factors such as heart failure and coronary artery disease a family history of early sudden cardiac death suggests a hereditary condition such as hypertrophic cardiopathy or an ion Channel defect on exam patients with mechanical ideologies of their cardiogenic Syncopy will often have a pathologic murmur possible ECG findings include a current arhythmia evidence of es schia or occult CAD or evidence of a pro rythmia syndrome such as a Long QT interval or delta waves if cardiogenic Syncopy is suspected a more thorough cardiac exam an echocardiogram and an ambulatory ECG monitor are indicated let me talk here about the variety of options for ambulatory ECG monitoring many patients with cardiogenic Syncopy will warrant inpatient admission and for inpatients they are put on something called Telemetry this is when a patient has several leads attached to their anterior chest wall which transmit the heart rhythm in real time to a monitor at the nurse's station for outpatients the most common ambulatory monitor was formerly a 1 to2 day halter monitor but there are several newer options in the US that are relatively inexpensive and which can be left on for a longer period of time one example is called the zop patch which is a waterproof monitor that attaches to the skin over the heart has no external wires to worry about and is worn under the clothes for up to two weeks if an echo and conventional ambulatory monitor both turn out to be unremarkable yet a cardiogenic cause is still suspected patients can receive an implantable loop recorder which is the size of a USB drive is inserted subcutaneously and can be left in place for several years in order to catch very infrequent but life-threatening arrhythmias if the patient then has another synal event the device can be interrogated afterwards to see definitively if an arhythmia was responsible the last Syncopy category is orthostatic Syncopy by definition orthostatic Syncopy is precipitated by moving from lying or sitting to the standing position a prodrome is almost always present and injury is uncommon patients tend to be older and Associated risk factors include Parkinson's disease diabetes alcoholism and new medication prescriptions particularly for alpha blockers ssris and antipsychotics as you might expect these patients have orthostatic hypotension on exam keep in mind that being orthostatic does not necessarily mean that the person's Syncopy was from the orthostasis since it's common for older patients with heart disease and on lots of cardiovascular medications to be incidentally orthostatic orthostatic hypotension has no relevant ECG findings if orthostasis is the suspected mechanism unless there is a strong contraindication to doing so give some IV fluids if the orthostasis results res olves it confirms the patient was dehydrated if it does not resolve and the patient is on a potentially causitive medication discontinue the med if feasible to do so and reassess orthostatics in a couple of days if neither hydration nor medication adjustments fix the problem the patient may have autonomic dysfunction which will require a more detailed investigation historically there has been a big problem with the over testing of patients presenting to the hospital with Syncopy patients with low pre-test probabilities of dangerous diagnosis found themselves getting serial troponin testing karate duplex ultrasounds brain MRIs eegs all kinds of stuff but aside from orthostatics the only other diagnostic test that is indicated in all patients presenting with Syncopy is an ECG that's the Practical diagnostic approach to Syncopy here are the major takeaway points for this topic the four components of Syncopy are an Abrupt loss of consciousness loss of postural tone short duration and spontaneous recovery there are many causes of Syncopy but they fall into three major categories reflex which includes vasil vagal cardiogenic and orthostatic Syncopy must be differentiated from Syncopy mimics most notably seizure Bas ofos Syncopy is the most common specific ideology while cardiogenic Syncopy is the most dangerous General category and the clinical features suggestive of a cardiogenic ideology are a lack of prodrome either no precipitant or precipitated by exertion a history of significant cardiovascular disease a family history of early sudden cardiac death a pathologic murmur on exam and an abnormal ECG