Syncope is a transient, self-limited loss of consciousness and postural tone due to reduced cerebral blood flow. It may occur suddenly, without warning, or may be preceded by presyncopal symptoms such as lightheadedness or faintness, weakness, fatigue, nausea, dimming vision, ringing in ears, or sweating. The syncopal pt appears pale and has a faint, rapid, or irregular pulse. Breathing may be almost imperceptible; transient myoclonic or clonic movements may occur. Recovery of consciousness is prompt if pt is maintained in a horizontal position and cerebral perfusion is restored.
APPROACH TO THE PATIENT Syncope
The cause may be apparent only at the time of the event, leaving few, if any, clues when the pt is seen by the physician. Other disorders must be distinguished from syncope, including seizures, vertebrobasilar ischemia, hypoxemia, and hypoglycemia (see below). First consider serious underlying etiologies; among these are massive internal hemorrhage, myocardial infarction (can be painless), and cardiac arrhythmias. In elderly pts, a sudden faint without obvious cause should raise the question of complete heart block or a tachyarrhythmia. Loss of consciousness in particular situations, such as during venipuncture or micturition, suggests a benign abnormality of vascular tone. The position of the pt at the time of the syncopal episode is important; syncope in the supine position is unlikely to be vasovagal and suggests arrhythmia or seizure. Medications must be considered, including nonprescription drugs or health store supplements, with particular attention to recent changes. Symptoms of impotence, bowel and bladder difficulties, disturbed sweating, or an abnormal neurologic exam suggest a primary neurogenic cause. An algorithmic approach is presented in Fig. 56-1.
Approach to the pt with syncope.
Syncope is usually due to a neurally mediated disorder, orthostatic hypotension, or an underlying cardiac condition (Table 56-1). Not infrequently the cause is multifactorial.
TABLE 56-1CAUSES OF SYNCOPE