Syncope resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Karol Gema Hernandez, M.D. [2]

Definition

Syncope is defined as a transient LOC, characterized by rapid onset, short duration and spontaneous complete recovery due to cerebral hypoperfusion.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

Common Causes

Management

Syncope in the Context of Transient LOC

 
 
 
 
 
 
 
Determine if there was LOC
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If yes:
❑ Rapid onset?
❑ Short duration?
❑ Spontaneous complete recovery?
 
 
 
 
 
 
If no:
Cataplexy
❑ Drop attacks
❑ Falls
❑ Functional /psychogenic pseudosyncope
TIA of carotid origin
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If no to ≥1; exclude the following before proceeding with syncope evaluation:
Coma
❑ Aborted SCD
Epilepsy
❑ Metabolic disorders:
Hypoglycemia
Hypoxia
Hyperventilation with hypocapnia
Intoxication
❑ Vertebrobasilar TIA
 
If yes:
❑ Transient LOC
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Non traumatic
 
Traumatic
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Suspect:
❑ Syncope
Seizure
❑ Psychogenic
 
 
 
 
 
 

Diagnostic Flowchart in Patients with Suspected Syncope

 
 
 
 
 
 
Suspected syncope:
❑ Initial Assessment
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Clinical history
❑ Physical examination (including supine and standing BP measurement after 3 minutes if OH is suspected)
❑ 12 Lead EKG
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Syncope
 
 
T-LOC non syncopal
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Certain diagnosis of syncope:
❑ Go to Diagnostic Evaluation algorithm for management of specific type of syncope
 
Uncertain etiologyConfirm with specific test OR specialist
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
High risk:
❑ Early Evaluation and treatment
 
Low risk, recurrent syncopes:
❑ Cardiac or neurally mediated tests as appropriate OR
Delayed treatment guided by EKG documentation
 
Low risk, single or rare syncope:
❑ No further evaluation
 
 



Algorithms based in 2009 ESC Guidelines for the Diagnosis and Management of Syncope. [3]

Do's

Don'ts

CSM should be avoided in patients with previous TIA or stroke within the past 3 months and in patients with carotid sinus bruits (except if carotid sinus Doppler studies excluded significant stenosis.

References

  1. Khoo, C.; Chakrabarti, S.; Arbour, L.; Krahn, AD. (2013). "Recognizing life-threatening causes of syncope". Cardiol Clin. 31 (1): 51–66. doi:10.1016/j.ccl.2012.10.005. PMID 23217687. Unknown parameter |month= ignored (help)
  2. Kapoor, WN. (2000). "Syncope". N Engl J Med. 343 (25): 1856–62. doi:10.1056/NEJM200012213432507. PMID 11117979. Unknown parameter |month= ignored (help)
  3. Task Force for the Diagnosis and Management of Syncope. European Society of Cardiology (ESC). European Heart Rhythm Association (EHRA). Heart Failure Association (HFA). Heart Rhythm Society (HRS). Moya A; et al. (2009). "Guidelines for the diagnosis and management of syncope (version 2009)". Eur Heart J. 30 (21): 2631–71. doi:10.1093/eurheartj/ehp298. PMC 3295536. PMID 19713422‎ Check |pmid= value (help).