SYNCOPE

Submitted by,
Nikketta Nunez
IV Part II BDS
SYNCOPE

Is a general term referring to a sudden, transient

loss of consciousness that usually occurs
secondary to a period of cerebral ischemia.
Also known as vasovagal syncope or neurogenic
syncope or psychogenic syncope.
PRE DISPOSING FACTORS

Factors that can precipitate vasodepressor

syncope are classified in to two groups;

PSYCHOGENIC FACTORS
NON PSYCHOGENIC FACTORS
PSYCHOGENIC FACTORS

Fright
Anxiety
Emotional stress
Receipt of unwelcome news
Pain (sudden & unexpected)
Sight of blood or instruments
These factors can lead to the development of the
“ fright or flight “ response in the patient and in the
absence of muscular movement by the patient ,
produce the transient loss of consciousness known
as vasodepressor syncope
NON PSYCHOGENIC
FACTORS
Erect sitting or standing posture
Hunger from dieting or missed meal
Exhaustion
Poor physical condition
Hot, humid, crowded environment
Male gender
Age between 16 and 35 years
Erect sitting and standing decreases cerebral blood flow below critical
levels.
Hunger can lead to decreased level of glucose supply to brain
Exhaustion can develop due to poor physical condition , hot, humid
and crowded environment
Men between the age group of 16 and 35 are mostly affected
CLINICAL
MANIFESTATIONS
Clinical signs and symptoms of vasodepressor syncope usually
develop rapidly in the presence of an appropriate stimulus.
Actual loss of consciousness does not normally occur rapidly.
There is usually sufficient time for them to sit or lie before they lose
consciousness.
The clinical manifestations of vasodepressor syncope can
be grouped into three definite phases. They are;

PRESYNCOPE
SYNCOPE
POSTSYNCOPE
 PRESYNCOPE

Early Signs and Symptoms

Feeling of warmth.
Loss of color; pale or ashen skin tone
Heavy perspiration
Feeling “bad” or “faint
Nausea
BP : base line or slightly lower
Late Signs and Symptoms

Pupillary dilation
Yawning
Cold hands and feet
Hypotension
Bradycardia
Visual disturbances
Dizziness
Loss of consciousness
 SYNCOPE

With the loss of consciousness breathing may become

Jerky
Quiet, shallow and scarcely perceptible
Cease entirely
Pupils dilate
Convulsive movements and muscular cramps of hands ,legs or facial
muscles may occur
Bradycardia
Heart rate less than 50 beats per minute is common
BP falls to an extremely low level
The pulse becomes weak and thready
Partial or complete airway obstruction due to muscular relaxation
Fecal incontinence may occur
 POSTSYNCOPE
With proper positioning recovery is rapid.
Patient may show pallor, nausea, weakness, and
sweating all which can last for few minutes to
hours.
Symptoms may persist for 24 hours.
Patient may experience a short period of confusion
or disorientation.
Arterial blood pressure begins to rise but normal
after several hours.
The heart rate returns slowly to normal.
The pulse becomes stronger.
The tendency of the patient to faint again may
persist for several hours, if the patient assumes
sitting position or stands too soon or quickly.
PATHOPHYSIOLOGY

Vasodepressor syncope is most commonly

precipitated by a decrease in cerebral blood flow
below critical level.
It is usually characterized by sudden drop in blood
pressure and slowing of heart rate.
 PRESYNCOPE

Stress due to fear or pain causes the body to

release catecholamines into circulatory system
which produce fright and flight response. This
causes increased muscular activity. So blood flow
to periphery increases.
But the planned muscular activity does not occur.
So pooling of blood in the periphery occurs. Thus
decrease venous return to heart.
This leads to a relative decrease in circulating
blood volume , a drop in arterial blood pressure and
decreased cerebral blood flow
 SYNCOPE

Occurs when cerebral blood flow is below critical

level (30 mL per 100 g of brain)
In upright position heart’s ability to pump this
critical volume is impaired and the minimal
cerebral blood flow is not reached.
Convulsive movements such as tonic or clonic
seizures of arms, legs may occur with onset of
syncope.
Cerebral ischemia lasting only 10 seconds can lead
to seizure activity.
RECOVERY

Recovery is hastened by placing the patient in

supine position with legs elevated.
This increases the venous return to heart and
increased cerebral blood flow. This results in
recovery.
The body will be fatigued and may require as long
as 24 hrs to return to normal.
Removal of the precipitating factor also helps in
speedy recovery.
 MANAGEMENT
Management of syncopal patients differs depending on the signs and
symptoms the individual exhibits.
Management for four separate stages can be done;
Presyncope
Syncope
Delayed recovery
Postsyncope
  PRESYNCOPE

STEP 1 P (position)
As soon as presyncopal signs and symptoms occur dental procedure
should be halted
The patient should be placed in the supine position with legs slightly
elevated
Muscle movements help in returning of the blood from the periphery
The position change usually halts the progression of syncope
STEP 2 A-B-C
(airway – breathing – circulation)
Assessment of airway and breathing should be
done
If required oxygen should be administered
using a full face mask
An ammonia ampule may be crushed under the
patients nose for speedy recovery.
STEP 3 D (definitive care)
Following management , attempts should be made
to determine the cause of syncope while the
patient recovers.
The planned dental treatment should be continued
only if both the doctor and patient feel its
appropriate.
 SYNCOPE

Proper management of vasodepressor syncope

follows the basic management protocol.
STEP I ASSESSMENT OF CONSCIOUSNESS
The patient suffering syncope demonstrates a
lack of response to sensory stimulation (“shake and
shout”)
“shake and shout”
STEP 2 ACTIVATION OF THE DENTAL OFFICE EMERGENCY SYSTEM

STEP 3 P (position)
The first and most important step in management of syncope is the
placement of the victim in supine position
Slight elevation of the legs helps increase the return of blood from
the periphery.
Failure to place the patient in supine position can lead to death or
permanent neurologic damage due to prolonged cerebral ischemia
This can occur within 2 – 3 mts if the victim is in erect posture
Females in the latter stages of pregnancy who lose consciousness
is an exception.
Supine Position
STEP 4 A B C
The victim must be assessed immediately and a patent airway is
ensured
Assessment of airway patency and adequacy of breathing is the next
step.
An adequate airway is present when the patient’s chest moves and
exhaled air can be heard and felt
Look ,Listen ,Feel
Technique
Spontaneous respiration is usually evident during
syncope.
Artificial ventilation may be necessary on those in
which spontaneous breathing ceases.
Positioning and establishing patent airway speeds
up recovery
Artificial Ventilation
To assess circulation carotid pulse must be
palpated.
Weak thready pulse is palpable in neck
Heart rate is quite low.
Carotid Pulse Palpation
STEP 5 ( definitive care)

 STEP 5a administration of oxygen

Oxygen can be administered at any stage of syncope

 STEP 5b monitoring of vital signs

Blood pressure
Heart rate
Respiratory rate should be monitored and recorded
STEP 5c additional procedures
Loosening of the binding clothes such as ties and collars
Use of respiratory stimulant such as aromatic ammonia.
To use ammonia vaporole ,it is crushed between fingers and the
patient is made to inhale it.
Ammonia having a noxious odor, stimulates breathing and
muscular movements.
Ammonia Vaporole
 A cold towel may be placed on patients forehead.
 Blankets can be provided if patient reports feeling cold or shivering.
 If bradycardia persists , an anti cholinergic, such as atropine, may be
administered either intravenously or intramuscularly.
 The precipitating stimulus such as syringes should be moved out of
sight.
 DELAYED RECOVERY

If the patient does not regain consciousness after

the procedures are performed or does not recover
completely in 15 – 20 mts a different cause for the
syncopal attack may be present.
Emergency medical service should be provided.
Basic life supporting measures should be
administered
 POSTSYNCOPE
After the recovery from syncope the patient should not be subjected
to additional dental treatment.
The possibility for second syncopal attack is more during
postsyncopal phase.
Prior to dismissal of patient ,the doctor should determine the primary
precipitating event and other factors that led to the syncope.
This is for planning future treatments.
Patient should not be allowed to leave the clinic
unescorted.
Providing an escort is mandatory whenever an
individual has lost consciousness
DRUGS USED
Oxygen
Spirit of ammonia (vaporole)
Atropine
Medical Assistance
A delayed recovery of consciousness or a delayed
return to normal status needs medical attention.
Emergency medical care should be provided for
such patients.
PREVENTION
Eliminating the factors that predispose the
individual to faint.
Proper positioning of the patient in the dental chair.
( semi supine position )
Anxiety relief for patients.
THANK YOU