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1. Overview Syncope Dr. Adenwali Hassan Ahmed: ( Mwn , Bsc -Medical Doctor, Bsc - Public Health Officer, Msc-Gyn / Obest .

2. Introduction of Syncope Syncope is also known as fainting. This is a temporary loss of consciousness with a quick recovery. Syncope is caused by decreased cerebral blood flow leading to transient loss of consciousness and postural tone, associated with spontaneous recovery. Most people don’t need follow-up treatment. However, you need treatment for certain causes, such as heart issues.

3. Overview Syncope (pronounced “sin- ko -pea”) is the medical term for fainting or passing out. Fainting is a brief loss of consciousness due to a drop in blood flow to the brain. It happens when you have a sudden, temporary drop in the amount of blood that flows to your brain. Most of the time, a harmless, short-term cause makes you faint . Pass out from weakness, physical or emotional distress due to a loss of blood supply to the brain

4. Cont--- Syncope can happen if you have: A sudden drop in blood pressure. A drop in your heart rate. Changes in the amount of blood in areas of your body.

5. Cont--- If you pass out, you’ll likely become conscious and alert after a few seconds or minutes. However , you may feel confused or tired for a bit. You can recover fully in minutes or hours .

6. Cont--- Syncope can be a sign of a more serious condition. It’s important to get treatment right away after you have an episode of syncope. Most people can prevent problems with syncope once they get an accurate diagnosis and proper treatment.

7. Types of Syncope Vasovagal syncope   (also called neurocardiogenic syncope). This is the most common type of syncope. Nearly half of syncope cases are the vasovagal type. Situational syncope ( a type of vasovagal syncope ). Situational syncope happens only during certain situations that affect the nervous system Postural or orthostatic syncope (also called postural hypotension ). Upright standing position.

8. Cont--- 4. Cardiac syncope ( Cardiac syncope is a transient loss of consciousness due to a defect, either structural or electrical, which prevents the generation of enough cardiac output to perfuse the brain adequately. 5. Neurologic syncope ( Neurologic syncope can happen when you have a neurological condition such as a seizure, stroke or transient ischemic attack (TIA). Other less common conditions that lead to neurologic syncope include migraines and normal pressure hydrocephalus ).

9. How common is syncope? Syncope is a common condition. It affects 3% of men and 3.5% of women at some point in life. Syncope is more common as you get older and affects up to 6% of people over age 75. The condition can occur at any age and happens in people with and without other medical issues .

10. Symptoms of syncope The most common syncope symptoms include: Nausea or vomiting Sweaty palms Blacking out Feeling lightheaded Falling for no reason Feeling dizzy Fainting , especially after eating or exercising Feeling unsteady or weak when standing Changes in vision , such as seeing spots or having tunnel vision Headaches

11. Causes syncope Syncope or passing out, happens when you don’t have enough blood flowing to your brain. There are many causes for this, depending on the type of syncope. Many people have a medical condition they may or may not know about that affects their nervous system or heart.

12. Cont--- You may also have a condition that affects blood flow through your body and causes your blood pressure to drop when you change positions (for example, going from lying down to standing).

13. TYPES: 1. Vasovagal syncope causes Vasovagal syncope happens when you have a sudden drop in blood pressure, which causes a drop in blood flow to your brain. Occurs when the part of your nervous system that regulates heart rate and blood pressure malfunctions in response to a trigger, such as the sight of blood. Your heart rate slows and the blood vessels in your legs widen (dilate). It often occurs after standing for a while or under emotional distress.

14. Cont--- Normally, when you stand up, gravity makes blood settle in the lower part of your body, below your diaphragm. When that happens, your heart and autonomic nervous system work to keep your blood pressure stable. In vasovagal syncope, your heart rate and blood pressure inappropriately decrease severely. This causes decreased blood flow to your brain and leads to passing out.

15. 2. Situational syncope causes Situational syncope happens only during certain situations that affect your nervous system and lead to syncope. Some of these situations are: Dehydration Intense emotional stress Anxiety Fear Pain Hunger

16. Cont--- Use of alcohol or drugs. Hyperventilation (breathing in too much oxygen and getting rid of too much carbon dioxide too quickly). Coughing forcefully, turning your neck or wearing a tight collar (carotid sinus hypersensitivity). Urinating ( micturition syncope)

17. 3. Postural syncope causes Postural syncope  (also called postural hypotension or orthostatic hypotension)  happens when your blood pressure drops suddenly due to a quick change in position, such as standing up after lying down. Certain medications and dehydration can lead to this condition.

18. Cont--- People with this type of syncope usually have changes in their blood pressure that cause it to drop by at least 20 millimeters of mercury (systolic/top number) and at least 10 millimeters of mercury (diastolic/bottom number) when they stand.

19. 4. Cardiac syncope causes Cardiac syncope can occur if you have a heart or blood vessel condition that affects blood flow to your brain. These conditions can include: Abnormal heart rhythm (arrhythmia ) Obstructed blood flow in your heart because of your heart’s structure (hypertrophic cardiomyopathy ).

20. Cont--- Blockage in your heart’s blood vessels (myocardial ischemia). Valve disease. Aortic stenosis (narrowing) . Blood clot. Heart failure If you have cardiac syncope, it’s important to see a cardiologist for proper treatment.

21. 5. Neurologic syncope causes Neurologic syncope can happen when you have a neurological condition such as a seizure, stroke or transient ischemic attack (TIA ). Other less common conditions that lead to neurologic syncope include Migraines and normal pressure hydrocephalus . An abnormal condition in which cerebrospinal fluid collects in the ventricles of the brain.

22. Consultation If you have syncope, you should see a provider who can refer you to a syncope specialist for a complete evaluation. You may then have one or more tests to help determine the cause of your syncope. These tests check things like: The condition of your heart. How fast your heart beats (heart rate). The amount of blood in your body (blood volume). Blood flow when your body is in different positions .

23. Syncope in Emergency Cont---

24. Syncope Definition : sudden and transient loss of consciousness and loss of postural tone accompanied by a rapid return to baseline Pathophysiology : dysfunction of both cerebral hemispheres or the brainstem (reticular activating system) usually from hypo-perfusion. The Reticular Activating System (RAS) is a neural system involved in the regulation of sleep–wake cycles, arousal, alertness, attention, and motor fight-or-flight responses

25. Cont--- Cardiac: Rhythm Disturbances: D ysrhythmias , Pacemaker issues Structural: outflow obstruction (aortic stenosis , hypertrophic obstructive cardiomyopathy (HOCM), Myocardial infarction (MI)) Other CV diseases: D issection , C ardiomyopathy , PE ( Pulmonary Embolism)

26. Cont--- Non- Cardiac: Reflex ( neurally mediated) Vasovagal : sensory or emotional reactions Orthostatic : postural related, volume depletion Situational: coughing, straining Carotid sinus pressure: shaving Subclavian steal: arm exercises

27. Cont--- Medications Calcium channel blockers ( eg ; Atenolol ) . B-blockers ( eg ; A mlodipine ) , Digoxin , Insulin. Prolonging meds, Drugs of abuse. Focal CNS - ( A focal neurologic deficit is a problem with nerve, spinal cord or brain function) Hypoperfusion - Hypoxia, epilepsy, dysfunctional brainstem

28. Assessment History : syncope character (ask about exertion!), cardiac risk factors, Comorbidities , Medication/drug use, family history Orthostatic symptoms Rule out seizure/stroke/head injury .

29. Cont--- Physical Exam: C ardiac exam (murmurs, rate) CNS exam.

30. Investigations Labs: CBC Glucose , lytes , Blood urea nitrogen (BUN), CK, B- Hcg This  test  measures the amount of  creatine kinase  ( CK ) in the blood. High levels of  CK  can indicate damage or disease of the skeletal muscles 

31. Cont--- ECG rates: Tachydysrhythmias - Tachydysrhythmias , or tachycardias , are classified as  dysrhythmias where the heart rate is greater than 100 beats per minute. There are several different types of tachydysrhythmias that include: Sinus tachycardia (ST): regular heart rhythm with a fast heart rate Sinus tachycardia is a regular cardiac rhythm in which the heart beats faster than normal

32. Cont--- Bradyarrhythmias - is an abnormally slow resting heart rate, typically below 60 beats per minute . A too-slow heart rhythm can result from changes in the heart's electrical system, a heart defect or other medical conditions.

33. Management General ABCs, monitors, oxygen, IV access Cardiogenic Syncope Consult cardiology for workup, pacemaker consideration Non- Cardiogenic Syncope Benign causes or low-risk syncope: discharge with general practitioner follow-up Consider outpatient cardiac workup

34. Medicines for syncope include : Midodrine Fludrocortisone ( Astonin or Florinef ) Midodrine 5mg tablets is used to treat low blood pressure (hypotension). It works by stimulating nerve endings in blood vessels, causing the blood vessels to tighten. Fludrocortisone , is a corticosteroid used to treat adrenogenital syndrome, postural hypotension and adrenal insufficiency. In adrenal insufficiency, it is generally taken together with hydrocortisone. Fludrocortisone The usual dose is 0.1 mg .

35. Cont--- Midodrine is used to treat orthostatic hypotension (sudden fall in blood pressure that occurs when a person assumes a standing position ). Midodrine is in a class of medications called alpha-adrenergic agonists. It works by causing blood vessels to tighten, which increases blood pressure

36. What is the prognosis of patients with syncope? 12 Month Prognosis for Patients Presenting with Syncope Group Mortality Incidence of Sudden Death Cardiac related 30 % 24 % Non cardiac related 12 % 4 % Unknown causes 3 % 3 %

37. Summary for Syncope

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