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Beyond the usual benefits of a firm diagnosis, there are two important reasons to correctly identify cardiogenic syncope. One study conducted by Martin et al developed and validated a clinical prediction rule for risk stratification of patients with syncope. Sustained ventricular tachycardia is most commonly due to a reentrant electrical wavefront involving a scar from a prior myocardial infarction. Supraventricular tachycardias and atrial fibrillation and atrial flutter are more common than ventricular tachycardia, but are less commonly associated with syncope. Symptomatic sinus bradycardia should be suspected particularly in elderly patients with evidence of a slow or varying sinus heart rate in the ED. Hypertrophic cardiomyopathy is a complex cardiac disease with a large spectrum of clinical variance.51 Its diagnosis is generally based on a combination of physical examination findings and diagnostic testing such as echocardiography. One special group of valvular patients is the group that has undergone artificial valve replacement. Other types of heart disease that can present as syncope include those that primarily affect the vascular system. Enough case reports exist regarding the vascular causes of syncope to make even the most seasoned emergency practitioner sweat. External or internal hemorrhage due to medical conditions or trauma may serve as an obvious or occult cause of syncope.
The vasodepressor syncopal syndromes are common but generally suggest low morbidity and mortality. Vertigo is a symptom that refers to an abnormal sensation of movement or rotation of the patient or his or her environment. A subarachnoid, subdural, or epidural bleed can also present as a syncopal episode, and obtaining a careful history is key. Migraine headaches can cause bizarre symptoms, including transient neurologic deficits and syncope. Hypoglycemia should be considered in any known diabetic patient presenting with a syncope-like syndrome. There are a variety of agents, including narcotics, benzodiazepines, and barbiturates, that can cause both central nervous system and respiratory depression.
Infection can be the primary cause of a syncopal episode or a secondary cause by leading to dehydration, sepsis, and hypotension.26 The history and physical examination will often identify the primary site of infection and the mechanism leading to syncope. Get full access to all EB Medicine articles published 3 years (or more) ago, including evidence-based, peer-reviewed diagnosis and treatment recommendations.
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First, syncope from cardiogenic causes has a one-year mortality rate ranging between 18% and 33%, compared to 0%-12% for non-cardiogenic causes and 6% for unexplained causes.1,4,5,14,44,45 Second, the treatment of many of the conditions responsible for cardiogenic syncope has advanced dramatically in the past decade. The authors first derived the prediction rule by reviewing the charts of 252 patients presenting to the ED with syncope. The diagnosis must be entertained in any patient with a history of prior myocardial infarction. Syncope, however, is more likely to occur if the rate is very rapid or if there is an abnormal vasomotor response.48 Patients with Wolff-Parkinson-White syndrome have a bypass tract between the atria and ventricles, allowing rapid conduction with a relatively short refractory period.
The emergency physician should check for current use of oral or ophthalmologic beta-blocking agents, calcium-channel blockers, and other agents or conditions that may increase vagal tone. A family history of sudden death or the use of medicines associated with this syndrome should raise suspicion further. Classic physical findings include a loud S-4 heart sound and a harsh and crescendo-decrescendo systolic murmur. For example, aortic stenosis has a characteristic diamond-shaped, midsystolic murmur most often radiating to the neck.
The combination of mechanical heart valves and syncope is an ominous sign that could suggest a number of complications, including valvular thrombosis, structural failure, paravalvular regurgitation, or ventricular dysrhythmia. For instance, syncope has been observed in 13% of patients with pulmonary embolism, and up to 20% of patients with a massive pulmonary embolism will complain of syncope.55-58 Each of these conditions is associated with its own classic signs and symptoms and will not be reviewed in detail in this article. Medical conditions may cause occult gastrointestinal or vaginal bleeding, or internal hemorrhage from a vascular catastrophe such as a ruptured abdominal aortic aneurysm. The key may be to keep a healthy suspicion for other, more serious conditions while making this diagnosis in patients with a suggestive history who appear well.
Keep this option in the differential diagnosis, especially in patients with a history of atypical migraines. Many case reports exist in the literature associating syncope and hypoglycemia.40,41 However, it is difficult to imagine that hypoglycemia can correct itself without intervention in order to fit with the standard definition of syncope that includes spontaneous and full resolution.
Any condition that leads to a decrease in oxygenation or ventilation can lead to hypoxia, and ultimately a syncopal episode.
They can range from fully conscious actions for secondary gain purposes to dissociative states where the patient has no conscious control over the activity. Never again spend hours trying to come up with questions of your own, never get caught at the last minute without great questions for your table topics sessions.
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Cardiovascular disease is associated with the highest long-term mortality, and patients are often at high risk for recurrent unstable events in the ED as well.
Many of the conditions can be successfully treated with medications and potentially cured with invasive procedures.
These patients are at particular risk for atrial fibrillation and atrial flutter with rapid, aberrant conduction to the ventricles via the bypass tract as well as cardiovascular instability. Evidence of second degree type II or type III heart block or a paced rhythm on the ECG should raise the suspicion for a symptomatic bradycardic dysrhythmia. Brugada syndrome appears to be most common in males from Southeast Asia and is suggested by characteristic ECG findings. In fact, syncope, along with angina and congestive heart failure, is one of the three most common presenting complaints of patients with aortic stenosis.50 This disease, along with conditions such as hypertrophic cardiomyopathy and other causes of structural heart disease, is usually associated with exertional syncope.
The murmur is best heard between the apex and the left sternal border.52 During strain, such as a Valsalva maneuver, the murmur will increase in volume secondary to an increase in gradient.
Features of the history that suggested vasodepressor as opposed to dysrhythmic syncope in one study included palpitations, blurred vision, nausea, warmth, diaphoresis, or lightheadedness prior to syncope, and the presence of nausea, warmth, diaphoresis, or fatigue following syncope.
That study found that tongue biting was found only in the seizure patients, but its absence did not exclude the possibility of a seizure.63 While a lateral tongue laceration appeared specific in this study, it has been observed in patients with psychogenic seizures.

They are generally believed to be caused by a transient ischemic attack involving the posterior circulation to the brain.
Decreased oxygen delivery to the central nervous system can also be caused by alterations in hemoglobin function. While psychiatric conditions that mimic syncope exist, they must remain a diagnosis of exclusion. Ventricular tachycardia may also occur in patients with dilated or hypertrophic cardiomyopathies, valvular diseases, and other uncommon conditions such as right ventricular dysplasia.
Vasodepressor syncope was associated with more than five seconds of warning symptoms and more prolonged recovery symptoms.49 The emergency physician should also be wary for significant trauma that may have occurred during the syncopal event. This can be seen in patients who are wearing neck ties or who have tight collars, or even during simple activities such as shaving. Carbon monoxide poisoning and methemoglobinemia can present with acute loss of consciousness. A study by Kapoor et al of syncope patients found that up to 20% of the population studied met diagnostic criteria for at least one major psychiatric disorder or substance abuse problem. If signs and symptoms are suggestive, a bedside echocardiogram may rapidly clarify the diagnosis.
Carotid sinus massage is a useful test in patients with suspected carotid sinus sensitivity.61 A positive test is defined as one that causes at least a three-second pause during massage of the carotid sinus. Peripheral vertigo is much more common, and patients who suffer from peripheral vertigo generally do not have a feeling of faintness or alteration in their level of consciousness. Methemoglobinemia is caused by a variety of agents, including nitrates, local anesthetics, and sulfonamides. Up to one-half of these patients with a psychiatric disorder did not have their disorder identified by the attending physician. Sign up for my email and my list of table topics questions will delivered right to your inbox. The treatment remains needle decompression of the pericardial fluid, either in the cardiac catheterization lab or the ED, if emergent.
This test can be difficult to master and should be reserved for those who have been trained in its proper use. Central vertigo may be due to a tumor such as an acoustic neuroma, multiple sclerosis, or neurovascular disease such as vertebrobasilar insufficiency. Pulse oximetry is unreliable in the setting of both of these poisonings, and the diagnosis should be made by direct measurement of a blood sample with a multiple wave-length co-oximeter.
In the setting of smoke inhalation from a residential or industrial fire and mental status changes, the diagnosis of cyanide toxicity must also be entertained. Although newer modalities such as the use of B-type natriuretic peptide have been investigated to aid in the diagnosis of congestive heart failure, it remains largely a clinical diagnosis. Features that distinguish vertigo syndromes from syncope include associated auditory complaints, evidence of nystagmus on ocular examination, or inducible nystagmus with the Hall-Pike maneuver.66,67 The Hall-Pike maneuver may only reproduce vertigo and nystagmus from cupulolithiasis, but not other peripheral causes of vertigo such as neuronitis. In the petroleum, rubber, and mining industries, exposure to hydrogen sulfide can cause altered mental status and syncope. Both cyanide and hydrogen sulfide arrest cellular respiration by interfering with mitochondrial cytochrome function. Cholinergic and anticholinergic toxidromes may include syncope among a variety of characteristic symptoms.
Toxic exposures should be in the differential diagnosis of syncope when several members of the same family or from the same location present to the ED simultaneously for evaluation.

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