see also: [[Syncope ECG patterns]], [[Seizures]] - [Rosen - Syncope](x-devonthink-item://DF5C89F4-4D57-47A2-AC05-5125FE78642E) - [Dunn - syncope](x-devonthink-item://702DB5A2-6D5E-4B0C-9390-3AE19ADC1EFC) > [!Key Points] > - syncope and near-syncope same workup > - 1 year mortality of cardiac syncope ~ 25% > - 1 year mortality of syncope with uncertain cause ~6% > - [mnemonic::CHESS, "WOBBLER"] > **Critical diagnoses associated with syncope** > - [[ACS|myocardial infarction]] > - life-threatening dysrhythmias > - [[Aortic dissection]] > - critical [[Aortic stenosis]] > - [[Syncope ECG patterns#Hypertrophic Cardiomyopathy]] > - pericardial tamponade > - [[Abdominal Aortic Aneurysm|AAA]] > - massive [[Pulmonary Embolism]] > - [[Subarachnoid haemorrhage|SAH]] > - toxic metabolic derangements > - severe hypovolaemia or haemorrhage > - ruptured [[Ectopic pregnancy]] > - [[Sepsis]] > - [[Right heart failure]] due to [[Pulmonary Hypertension]] ![[Pasted image 20240308225640.png]] ![[Pasted image 20240308225711.png|management algorithm Rosen]] ![[Pasted image 20240308225856.png|Diagnostic algorithm rosen]] # Types 1. [[Syncope ECG patterns|Cardiac Syncope]] -- mechanical (PE, tamponade, aortic stenosis), dysrhythmias 2. Reflex syncope -- vasovagal, carotid sinus syndrome, situational 3. Orthostatic syncope -- drug induced, volume depletion, neurogenic # workup - get ECG to rule out [[Syncope ECG patterns#Long QT]] as cause - Ischemia, bradycardias, arrhythmias, WPW, Brugada, HCM, long QT major "WOBBLER" -- ECG findings besides ischaemia or overt arrhythmias - WPW - Obstruction of AV node (AV block) - Brugada - blocks - LV hypertrophy, HOCM - Epsilon wave (ARVC) - Repolarisation abnormality (long QT) # Syncope scores ![[Pasted image 20240721222116.png]] ## SF syncope rule ==CHESS== -- all negative is low-risk (but cannot necessiarily send home if all negative) - CHF history - haemotocrit <30 - ECG (abnormal) - shortness of breath symptoms - systolic BP <90 > - validated score looking at 7 day adverse events > - sensitivity ~ 98%, low specificity (~56%) ## canadian syncope rusk score - more useful than SF syncope but a bigger hassle to do | factor | score | | ------------------------------ | ----- | | ED dx of vasovagal syncope | -2 | | predisposition to vasovagal sx | -1 | | hx of heart disease | 1 | | any SBP <90 or >180 | 1 | | QRS > 130 ms | 1 | | QRS axis < -30 deg or >100 deg | 1 | | Trop > 99th percentile | 2 | | QTc > 480ms | 2 | | ED dx of cardiac syncope | 2 | score ≤0 is low risk (0.4-2% 30 day risk of serious outcome), 1-3 medium risk (3-8% risk), >3 high risk (13% risk) # Seizure vs syncope table #tables | feature | syncope | seizure | | ----------------------------- | ------------------------------------------ | ------------------------------------------------------ | | aura | no | sometimes | | onset | commonly standing | at any time | | lightheaded/<br>"pre-syncope" | common | no | | tonic-clonic movements | no; just myoclonus | yes | | eye movements | usually deviate upwards at onset | may deviate laterally, especially during focal seizure | | tongue biting | uncommon<br>if present, tip of tongue | common<br>lateral tongue | | incontinence | rare | common | | duration of unconsciousness | < 1 min | >2 min | | post-event confusion | < 5 min | usually > 5 min | | post-event pulse rate | usually slow (unless tachycardia is cause) | fast | # non-cardiac causes of syncope - Reflex: - Vasovagal: Sudden sensation of pain, prolonged standing. - Situational: Strain with closed glottis, micturition, defecation, swallow. - Carotid sinus: Tight collar, head turning. - Orthostatic: - Hypovolaemia (Blood loss, fluid loss) - Addison’s - Vascular: - Aortic dissection (Thoracic or abdominal) - Pulmonary Embolism - Subclavian steal - CNS: - SAH, TIA, migraine, subclavian steal, Shy-Drager - Autonomic dysfunction - Medication: - Cardiac: B-blocker, CCB, nitrates, ACEi, diuretics. - Other: anti-psychotics, anti-depressants, anti-parkinsonian - Party: Cocaine, sildenafil, alcohol, poppers - Psych: - ~50% in young adults - Other: - Hypoglycaemia - Anaemia