syncope

1. Dr Ng JoYe
Syncopal Attack

2. What is Syncope ?
Transient loss of conciousness (TLOC) attributable to global
cerebral hypoperfusion, characterized by
Rapid onset
Brevity
Spontaneous recovery

5. Initial management
ABC
Vital sign and ECG
IV line if suspicious of volume loss

6. Patient Assessment
The initial evaluation should answer three key question .
Is this a true syncope ?
Has the aetiological diagnosis been determined?
Are there data suggestive a high risk of cardiovascular
events or death?

7. 1. Diagnosis of syncope
Was LOC complete ?
Was LOC transient with rapid onset and short duration ?
Did the patient recovery spontaneously, completely and
without sequelae?
Did the patient lose postural tone ?

8. 2. Aetiology diagnosis
Questions about circumstances just prior to attack
Position (supine, sitting , standing)
Activity (rest, change in posture, during or immediately after
exercise, during or immediately after urination, defecation
or swallowing)
Predisposing factors (crowded or warm place, prolonged
standing post-prandial period) and of precipitating events
(fear, intense pain, neck movements)
Questions about onset of the attack
Nausea, vomiting, feeling cold, sweating, pain in chest, pain
in neck, or shoulders,

9. Questions about attack (eye witness)
Skin color (pallor, cyanotic)
Duration of loss of consciousness
Movements ( tonic-clonic, etc.)
Tongue biting
Questions about the end of the attack
Nausea, vomiting, diaphoresis, feeling cold, muscle aches,
confusion, skin color, wounds

10. Questions about background
Number and duration of syncope spells
Family history of arrhythmic disease or sudden death
Presence of cardiac disease
Neurological disease (Parkinsons, epilepsy, narcolepsy)
Internal history (Diabetes)
Medications (Hypotensive, negative chronotropic and
antidepressant agents)

11. 3. Risk stratification
San Francisco Syncope Rule (SFSR)
C – congestive heart failure
H – Hematocrit < 30 %
E – ECG abnormal
S – shortness of breath
S – systolic < 90mmHg at triage
Sensitivity : 98%, specificity 56 %
Risk of serious outcome or death at 30 days

12. 3. Risk stratification
 ROSE (Risk Stratification of Syncope in the Emergency
Department)
B - Brain natriuretic peptide level ≥ 300 pg per mL
- Bradycardia < 50 bpm
R – rectal examination ( fecal occult blood )
A – Anemia < 9g/L
C – Chest pain associated with syncope
E – ECG (Q wave not on lead III)
S – saturation < 94 % under RA
Sensitivity : 87%, specificity 66 %
Risk of serious outcome or death at 30 days

13. 3. Risk stratification
OESIL (Osservatorio Epidemiologico sulla Sincope nel Lazio)
Age > 65 years old
History of cardiovascular disease
Syncope without a prodrome
Abnormal ECG
risk of all-cause mortality at 12 months

14. High Risk category
 AMI
 Myocarditis
 Dysrhythmias
 Second and third degree heart
block
 Pacemaker dysfunction
 VT
 Prolonged QT syndrome
 Brugada syndrome
 Ectopic pregnancy
 Antepartum haemorrhage
 Severe GI bleed
 Pulmonary embolism
 SAH
Actions :
1. Transfer patient to resus
2. Immediate resuscitation
3. Consider admission to ICU
4. Refer to relevant discipline stat .

15. Long QT syndrome
Bazett: 1920 QTc=QT/square root of the RR
Abnormal if QTc in males >470 ms and females of > 480 ms
Borderline prolonged QTc 450-470 ms
Average QTc for someone with the LQTS is 490 ms

17. Causes of prolonged QT interval
Drugs : Antidysrhythmics (eg: quinidine, procainamide,
disopyramide, sotalol and amiodarone). Psychotropic agents
Electrolyte abnormalities : hypo K, Mg,Ca
Cardiac abnormalities : MI, Myocarditis
Intracranial Disease : SAH
Altered nutritional state : Liquid protein modified fast diet/
starvation
Congenital : Jervell and Lange- Nielsen syndrome , Romano-
Ward syndrome, Sporadic type

18. Diagnostic Criteria for LQTS
 EKG findings
 QTc
 >480 3
 460-470 2
 450 (male) 1
 Torsdade De Pointes 2
 T-wave alternans 1
 Notched T wave in 3 leads 1
 Low heart rate for age 0.5
 Clinical History
 Syncope with stress 2
without stress 1
 Congenital deafness 0.5
 Family history
 Definite LQTS 1
 Unexplained SCD in immediate family member that is less than 30 years of age
0.5

19. <1 points low probability
2-3 points intermediate probability
 >4 points high probability

20. Brugada syndrome
Cause of Sudden Unexplained Nocturnal Death Syndrome in
SEA

21. Brugada syndrome diagnostic criteria
1. Type 1 ECG pattern in > 2 precordial leads (V1-V3), in
conjunction with one of the following :
 Documented VF
 Polymorphic VT
 Family hx of sudden cardiac death < 45 yo
 Coved type ECG in family member
 Syncope
 Nocturnal agonal respiration
 Inducibility of VT with programmed electrial stimulation
2. Conversion of type 2/3 to type 1 after Sodium blocker
administration in conjuntion with above clinical features

23. Moderate Risk category
 Aortic stenosis
 Hypertropic obstructive
cardiomyopathy (exertional
syncope)
 Suspected mild CVA / TIA
 Mild blood loss
 Orthostatic syncope (volume loss)
 Hypoglycemia
 Patients with IHD
 CCF
 SVT
 Drug induced syncope
Actions :
1. Stablilize the patient
2. Consider admitting the patient to observation unit.

24. Low Risk category
 Vasovagal/neurocardiogenic
syncope eg :
 Micturation/defaecation syncope
 Postprandial
 Tussive
 Psychogenic syncope
 Anxiety and panic disorder
 Unexplained syncope
Actions :
1. Excluded all high risk and moderate risk condition
2. Observe > 2 hrs
3. Discharge if the patient is alert and attentive and parameters are stable
4. For patient with recurrent vasovagal syncope, consider referral to cardiology.

25. Actions :
1. Transfer patient to resus
2. Immediate resuscitation
3. Consider admission to ICU
4. Refer to relevant discipline stat .

27. References
Shirley O, Sim TB. Syncope. Guide to The Essentials in
Emergency Medicine.
European Heart Journal (2009) Guideline for the diagnosis
and management of syncope.
Saklani et al. American Heart Association. Ciruculation
2013: syncope