Syncope refers to a “transient loss of consciousness due to reduced cerebral perfusion.” Transient loss of consciousness is a very common presentation, affecting up to half the population in the UK at some point in their lives. Patients often describe these episodes as “blackout” or “collapse”. Cardiovascular diseases are the commonest cause however the differentials are wide (therefore a thorough clinical history, examination and focused investigation are absolutely essential to illicit the underlying cause!)
(important to obtain eyewitness/collateral history)
-Position: standing, lying down, sitting
-Activity: during/after exercise, change in posture, micturition, coughing
-Prodromal symptoms?: lightheadedness, headache, aura, chest pain,
breathlessness,dysarthria, limb weakness etc.
-Establish whether there was Loss of Consciousness! -duration
-Jerky movements that may suggest a seizure (cerebral hypoxia of any cause may
also cause transient abnormal movements)
-Incontinence, up-rolling of eyeball, tongue-biting
-Injuries sustained during the event
-Speed of recovery
-Level of consciousness on recovery
Past medical history: diabetes, hypertension, epilepsy, ischemic heart disease
Medication history: insulin, anti-hypertensives, NSAIDs etc.
Menstrual/Gynaecology history: pregnancy, LMP, menorrhagia etc.
For all patients:
These initial investigations will identify the underlying cause in over a third of patients presenting with syncope
-BP Readings at supine position then immediately & after 3mins of standing upright
-Positive result: Drop of 20mmHg Systolic and 10mmHg Diastolic BP
The choice of these further investigations will depend upon clinical suspicion from history, examination and initial investigations.
-patient lies flat for 10mins and attached to cardiac & BP monitor
-tilted upright at 70degrees and observed for 30mins for signs of syncope.
GTN spray is sometimes used.
-DO NOT perform if carotid bruit present or recent stroke
-massage carotid sinuses for 6 seconds while monitoring BP & ECG
-positive: sinus pause for >3s or fall in systolic BP >50mmHg
Do not forget to differentiate syncope from-
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