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SYNCOPE Etiologies: P-A-S-S O-U-T (mnemonic) P ressure (hypotensive causes) A rrhythmias S eizures S ugar (hypo/hyperglycemia) O utput (cardiac)/O2 (hypoxia) U nusual

causes T ransient Ischemic Attacks & Strokes, CNS dz's

Syncope Evaluation The following pathway presents a possible diagnostic sequence based on the preceding information. H*P*, EKG, Labs: (CBC, Lytes, BG, BUN/Cr. Ca+, Sao2) *H&P should include BP (lying & standing BP's) If: Structural heart disease** or Cardiac sx &/or risk or Abn. EKG** or Unsecure Home Environ. or Seizure or Acute neuro sx. or Significant injury ** Structural heart disease = CAD, CHF, Valcular disease, cong. heart disease **Abnormal EKG: old MI, BBB, arrhythmias, conduction syst. disease If none of the above

****************************************************** P ressure 1) Vasovagal 2) Orthostatic Hypotension Causes a) Volume Loss d) Primary Autonomic dz.* b) Medications e) Secondary Autonomic dz.# c) Situational ** f) Adrenal Insufficiency A rrhythmias - Bradyarrhythmias, Tachyarrhythmia's (SVT, NSVT, A.F.), pacemaker malfunctions S eizures S ugar (hypo/hyperglycemia) O utput (cardiac)/O2 (hypoxia) CARDIAC -A.S., P.S., M.S. -IHSS -Cardiomyopathies: -Atrial Myxoma -Cardiac Tamponade -Aortic Dissection -M.I. -CHF U nusual causes Causes:-Anxiety -Panic disorder -Somatization disorder -Major depressive disorder -Hyperventilation syndrome PULMONARY (O2) -P.E. -Pulm. HTN -COPD exacerbation -C.O. poisoning

If YES to any of the preceding consider initial INPATIENT management

INPATIENT for -MI r/o -Cardiac Monitor -If Seizure sx do EEG -If Cardiac output sx's do Echo -If neuro sx's or signs do CT

Negative w/u


Structural heart dz? or Abn. EKG? or Cardiac risk or sx? YES

Consider OUTPATIENT (if home support system secure)

History suspicio us for arrhyth mia?

Stress Test (Exercise stress echo, or Pharmacologic stress test)

T ransient Ischemic Attacks & Strokes (and other CNS causes) NO Causes: -CVA's -TIA's (vertebro-basilar) -Subarachnoid hemorrhage -Subdural hematoma -Subclavian steal -Basilar artery migraine -CNS mass effect: (tumor, edema, AVM) Complete the "PASS OUT" evaluation Cardiology & EPS? YES Negative

********************************************************* *Primary ANS dz:Idiopathic, Multi-System Atrophy(Shy-Dragger), Parkin's dz #Secondary ANS dz:Neuropathic (DM, amyloid, alcoholism, autoimmune Cancer, B12 def., porphyria, renal failure) **Situational: micturition, postprandial, cough, carotid sinus sensitivity defecation, laughing & postprandial evv9/7/08



Tilt Table?

Negative (but still suspect arrthythmia)

Event Monitor (for brady-arrhythmias)