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syncope / near syncope


syncope and falls in the elderly

  • an ever increasing problem compounded by increasing number of elderly population and overzealous Rx of hypertension
  • elderly usually do not have recall of a syncopal event causing a fall
  • vasovagal syncope / neurocardiogenic syncope becomes a much more uncommon cause of syncope as age increases above 35 yrs age and thus the elderly require a low suspicion for other cardiac or neurologic causes, in particular:
        • if an elderly patient requires admission for the episode of syncope:
          • if clinical features of PE (eg. RR > 20, BP < 110, HR > 100), known active cancer, or probable or PH DVT then test for PE
          • note that patients with alternative causes for syncope still had a 12% probability of having a PE causing the syncope and their PEs they tend to be more proximal and life-threatening
          • if no clinical features PE/DVT/active cancer, then probability of “occult PE” is around 5% and if you believe the mortality benefit of anticoagulation is 3.2% or more which is probably the case, then we should consider testing with D-Dimer
    • carotid sinus syncope
      • Carotid sinus massage should be considered in both supine and upright positions whilst cardac monitored as patients with this cause develop 5-10 secs of asystole with often delayed return of BP. These patients do well with cardiac pacemaker.
    • Cardiac arrhythmias
    • orthostatic hypotension due to medications, dehydration (which most elderly have), and age or disease related impaired autonomic systems such autonomic neuropathy and post-prandial hypotension

Mx of the child / adolescent with syncope

Mx of the older adult with syncope

  • history, medication history (is the patient on anticoagulants, etc), and examination (is there evidence of acute stroke?) to ascertain potential cause and exclude any injuries due to a fall
  • targeted investigation which should also include:
    • blood sugar level
    • vital signs - is the patient hypotense or septic?
    • 12 lead ECG
    • cardiac monitor whilst in ED
    • baseline bloods:
      • FBE, U&E
      • consider troponin, Ca,Mg,PO4 if possible primary cardiac arrhythmia
      • HCG if woman of child bearing age
      • Group and Hold if possible acute blood loss
      • blood cultures, serum lactate, LFTs, lipase, CRP, CXR, urinalysis, etc if sepsis is likely
    • urgent CT brain if ongoing decreased cognition, meningism, focal neurology or sudden onset headache
    • urgent FAST USS for intrabdominal bleeding, and also assessment of possible abdominal aortic aneurysm (AAA) if hypotension or abdominal pain are features
    • consider admission for 12-24hrs of cardiac monitoring if possible primary cardiac arrhythmia
      • eg. elderly with syncope whilst sitting and no cause found
syncope.txt · Last modified: 2019/08/12 00:40 by

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