Syncope is a transient, self-limited loss of consciousness due to acute global impairment of cerebral blood flow. It may occur suddenly, without warning, or may be preceded by presyncopal symptoms such as light-headedness 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 and complete 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 examination suggest a primary neurogenic cause. An algorithmic approach is presented in Fig. 50-1.
Approach to the pt with syncope.
Syncope is usually due to a neurally mediated disorder, orthostatic hypotension, or an underlying cardiac condition (Table 50-1). Not infrequently the cause is multifactorial.
TABLE 50-1CAUSES OF SYNCOPE |Favorite Table|Download (.pdf) TABLE 50-1CAUSES OF SYNCOPE
|A. Neurally Mediated Syncope |
| Vasovagal syncope |
| Provoked fear, pain, anxiety, intense emotion, sight of blood, unpleasant sights and odors, orthostatic stress |
| Situational reflex syncope |
| Pulmonary |
| Cough syncope, wind instrument player’s syncope, weightlifter’s syncope, “mess trick”a and “fainting lark,”b sneeze syncope, airway instrumentation |
| Urogenital |
| Postmicturition syncope, urogenital tract instrumentation, prostatic massage |
| Gastrointestinal |
| Swallow syncope, glossopharyngeal neuralgia, esophageal stimulation, gastrointestinal tract instrumentation, rectal examination, defecation syncope |
| Cardiac |
| Bezold-Jarisch reflex, cardiac outflow obstruction |
| Carotid sinus |
| Carotid sinus sensitivity, carotid sinus massage |
| Ocular |
| Ocular pressure, ocular examination, ocular surgery |
|B. Orthostatic Hypotension |
| Primary autonomic failure due to idiopathic central and peripheral neurodegenerative diseases—the “synucleinopathies” |
| Lewy body diseases |
| Parkinson’s disease |
| Lewy body dementia |
| Pure autonomic failure |
| Multiple system atrophy (the Shy-Drager syndrome) |
| Secondary autonomic failure due to autonomic peripheral neuropathies |
| Diabetes |
| Hereditary amyloidosis (familial amyloid polyneuropathy) |
| Primary amyloidosis (AL amyloidosis; immunoglobulin light chain associated)...|