SYNCOPE

  • CC: Witnessed/unWitnessed transient loss of consciousness with rapid & spontaneous recovery
    -- Inciting Events: (after prolonged standing, upon staning, stressors, pain, PO intake, cough, hot weather)
    -- Prodrome: (dizziness, nausea, abdominal pain, warmth/flushing)

  • PN: no prolonged postictal state DENIES tongue laceration (side vs front), loss or urine or stool, palpitations, chest pain, SOB, no palpitations, no focal weakness, no intoxication

  • mHx: seizure, diabetes, CAD, CHF, valvular disease, arrythmia, HTN, DM, seizure disorder, anemia, PD

  • sHx: tobacco, EtOH, drug use, poor hydration

  • initial DATA:

  • pending DATA:

  • MEDS: antihypertensives, diuretics, beta blockers, nitrates, QT meds, insulin,anticoagulants, sedatives,

  • DDX:

    • Reflex / Vasovagal/ situational Prodrome: nausea, warmth, sweating, tunnel vision, after Pain, stress, emotion, blood draw, Heat, prolonged standing or situational during urination, defecation, coughing, or eating

    • Orthostatic Hypotension, Prodrome: dizziness/lightheadedness on standing, iso Dehydration, poor PO intake and Diuretics, antihypertensives use AND after Standing after sitting/lying

    • Medication / Substance Related, BP meds, nitrates, beta blockers, Sedatives, alcohol

    • possible Cardiac Arrhythmia, or Structural Cardiac Disease (AS,HF,PHtn) with NO Prodrome and Hx ....

    • Volume Loss / Hemorrhage from GI bleed, anemia, vomiting/diarrhea, or sepsis causes hypotension

    • Neurologic Mimics Seizure, Stroke/Transient Ischemic Attack, or Migraine, with tongue bite, focal deficits

  • COURSE:
    -- work up: orthostatics, CBC,BMP, EKG, tele, Echo or stress test (if concern for cardiac etiology), CT Head (if head strike, blood thinner use, focal deficit), CTPE (if tachy or at risk)

Plan

  • f/u orthostatics (change of >20/10)

    • d/c contributing meds;  midodrine 5-20mg TID during waking hours and upright,

  • IVF PRN - now s/p ***

  • trend daily labs

  • K >4, Mg >2

  • on telemetry

  • if Orthostatic Hypotension, IV/PO hydration, Hold/reduce BP meds,Slow position changes,Compression stockings

  • if c/f cardiac etiology (arrythmia.structural heart disease) consult cardiology consider Holter Monitor, echo, and tx underlying

  • if Reflex / Vasovagal Trigger avoidance (heat, prolonged standing)

  • if Situational Syncope Identify trigger (micturition/cough/defecation/swallow) tx if possible

  • if Volume Loss / Hemorrhage IVF, CBC trend q6–12h if bleeding, Type & screen transfuse if needed TX underlying issue

  • if neurological, contact neurology

  • if Medication / Substance Hold offending meds, Reduce polypharmacy, ox screen if indicated

  • PT/OT to follow and eval ( orthostatic)