Pre-syncope is dizziness and a feeling of impending fainting without LOC. It is usually classified along with syncope and discussed, since the causes are the same.

Syncope is a sudden, brief loss of consciousness (LOC, loss of conciousness) with loss of postural tone, followed by spontaneous recovery. The patient is motionless and weak, and usually has cold extremities, a weak pulse and shallow breathing. Sometimes short, involuntary muscle twitches occur which resemble a spasm. Pre-syncope is dizziness and a feeling of impending fainting without LOC. It is usually classified along with syncope and discussed, since the causes are the same. Seizures can cause sudden LOC, but are not considered syncope. However, must be considered seizures in patients who are apparently presented with syncope, because the history may be unclear or unavailable and some seizures do not cause tonic-clonic convulsions. Furthermore enters a short (<5 seconds) seizure sometimes with true syncope. The diagnosis depends on a careful history, eyewitness accounts or a random inspection during the event. Pathophysiology Most syncopation resulting from insufficient cerebral blood flow. Some instances include a sufficient blood flow with but insufficient cerebral substrate (oxygen, glucose, or both). Inadequate cerebral blood flow Most deficiencies in cerebral blood flow resulting from decreased cardiac output (CO). Reduced CO can be caused by heart disease, which obstruct the outflow heart disease systolic dysfunction heart disease diastolic dysfunction arrhythmias (too fast or too slow) conditions which reduce venous return An outflow obstruction, can be enhanced by physical activity, vasodilation or hypovolemia (especially the aortic and hypertrophic cardiomyopathy) that may precede syncope. Arrhythmias causing syncope, if the heart rate is too fast to allow adequate ventricular filling (z. B.> 150-180 beats / min), or too slow to ensure adequate discharge (z. B. <30-35 beats / min). The venous return can be prepared by hemorrhage, increased pressure in the chest cavity, increased vagal tone (which may also reduce heart rate), and the loss of sympathetic tone (eg., By substances carotid sinus pressure, autonomic dysfunction) can be reduced. Syncope, which includes these mechanisms (except hemorrhage) is often referred to as vasovagal or neurokardiogen and is widely used and benign. Orthostatic hypotension is a common cause of benign syncope, resulting from a failure of normal mechanisms (z. B. sinus tachycardia, vasoconstriction, or both) that compensates for the temporary reduction of the venous return, which occurs in a standing position. Cerebrovascular disease (eg., Stroke, transient ischemic attack) rarely cause syncope, because most of them do not include zentrencephalischen structures that must be affected to cause LOC. However, ischemia of basilar artery can cause syncope due to a transient ischemic attack or migraine. Rarely develop in patients with severe cervical spondylosis arthritis or vertebrobasilar insufficiency with syncope when the head moves in certain positions wird.Unzureichendes cerebral substrate The CNS requires oxygen and glucose to function. Even in normal cerebral blood flow caused a significant deficit of one of the two LOC. In practice, the primary cause is hypoglycemia because hypoxia rarely developed in a way that abrupt LOC caused (except for incidents in flying or diving). LOC due to hypoglycemia is rare as abruptly as syncope or seizures because warning symptoms (except in patients taking beta-blockers). However, the onset may be unclear to the auditor if the event was not observed. Etiology The causes are generally classified on the mechanism (see table: Some causes of syncope). The most common causes are Vasovagal (neurokardiogen) Idiopathic Many cases of syncope never received a firm diagnosis, but cause no apparent damage. A smaller number of cases has a serious cause, mostly cardiac. Some causes of syncope Cause Suggestive Findings Diagnostic Approach * obstruction of cardiac training or inflow valvular heart disease: aortic or mitral stenosis, tetralogy of Fallot, prosthetic Klappendehiszenz or thrombosis Young or old patient syncope often during physical exertion; rapid recovery heart murmur echocardiography Hypertrophic cardiomyopathy, restrictive cardiomyopathy, cardiac tamponade, myocardial rupture Young or old patient syncope often during physical exertion; rapid recovery heart murmur echocardiography Cardiac tumors or thrombi syncope can positionally be Normally noise (possibly variable) Peripheral embolic phenomena echocardiography pulmonary embolism, amniotic fluid embolism, or rarely air embolism usually very embolism, accompanied by dyspnea, tachycardia or tachypnea Often risk factors for pulmonary embolism D-dimer CT angiography or Ventialtions perfusion scintigraphy cardiac arrhythmia Bradyarrhythmias (eg. B. from a dysfunction of the sinus node, high-grade AV block, drugs †) syncope occurs without warning; immediate recovery on awakening can in any position occur bradyarrhythmias common in the elderly patients who take medication to himself, especially antiarrhythmics or other drugs that prolong the QT interval in susceptible patients Structural heart disease When ECG is unclear is Holter monitor or event recorder or sometimes another implanted loop recorder considered Electrophysiological testing if abnormalities are observed or high levels of suspicion serum electrolytes when a clinical reason for abnormality (eg. as taking a diuretic, vomiting, diarrhea) tachyarrhythmias, either supraventricular or ventricular (z. B. due to ischemia, heart failure, myocardial disease, drugs †, Elektrolytabnormalitäten, arrhythmog enes right ventricular dysplasia, long-QT syndrome, Brugada syndrome, pre-excitation) syncope occurs without warning; immediate recovery on awakening can at each position occur patients who take medication to himself, especially antiarrhythmics or other heart medications structural heart disease when ECG is unclear is Holter monitor or event recorder considered Electrophysiological testing if abnormalities are observed or high levels of suspicion serum electrolyte when a clinical reason for abnormality (eg. as taking a diuretic, vomiting, diarrhea) Ventricular dysfunction Acute myocardial infarction, myocarditis, systolic or diastolic dysfunction, cardiomyopathy syncope is a rare symptom of myocardial infarction (most of these patients are elderly) with Arrhyth mie or shock troponin i. S. ECG echocardiography Sometimes cardiac MRI cardiac tamponade or -konstriktion jugular venous collection; Paradoxical pulse> 10 echocardiography Sometimes CT Vasovagal (neurokardiogen) Increased intrathoracic pressure (eg, tension pneumothorax, coughing, straining to urinate or stool, Valsalva maneuver.) Warning symptoms (eg, dizziness, nausea, sweating.); Recovery usually prompt, but not immediately (5-15 minutes longer or, sometimes hours) precipitant usually seen Clinical Evaluation Strong emotions (eg. As pain, fear, sight of blood) warning symptoms (eg. As dizziness, nausea , Sweat); Recreation promptly, but not right away (5-15 min, but sometimes hours) release is generally seen Clinical evaluation carotid sinus pressure warning symptoms (eg, dizziness, nausea, sweating.); Recreation promptly, but not right away (5-15 min, but sometimes hours) release is generally seen Clinical evaluation swallowing warning symptoms (eg, dizziness, nausea, sweating.); Recreation promptly, but not right away (5-15 min, but sometimes hours) release is generally seen Clinical evaluation anaphylaxis medication administration, insect bite, allergy history allergy tests orthostatic hypotension drug † symptoms develop within minutes when adopting an upright position Waste blood pressure when standing during the investigation Clinical evaluation Sometimes tilt-table testing Autonomic dysfunction symptoms develop within minutes when adopting an upright position drop in blood pressure when standing during the investigation Clinical evaluation Sometimes tilt-table testing deconditioning caused by prolonged bed rest symptoms develop within minutes when adopting an upright position drop in blood pressure when confessed during the investigation Clinical evaluation sometimes tilt-table testing anemia Chronic fatigue, sometimes dark stool, severe menstrual Complete blood counts cerebrovascular transient ischemic attack or stroke Eder basilar artery Sometimes cranial nerve deficits and ataxia CT or MRI migraine aura with blurred vision, photophobia; unilateral Clinical Evaluation Other Prolonged standing can be seen through history; no other symptoms Clinical Evaluation pregnancy Healthy woman of childbearing age; no other symptoms urine pregnancy test hyperventilation often tingling around the mouth or in the fingers in front of the syncopation usually in the context of an emotional situation evaluation hypoglycemia treated Normally an early or unrecognized pregnancy Clinical clouding of consciousness up, beginning seldom abruptly, sweating, piloerection Usually history of diabetes or Insulinom glucose measurement from capillary blood of the fingertip in response to glucose infusion Psychiatric disorders No real syncope (patient can partially or inconsistent response be able during the event) Normal investigation Often history of psychiatric disorder Clinical evaluation * ECG and pulse oximetry are carried out at all. † Some drug-related causes of syncope. Some drug-related causes of syncope mechanism as bradyarrhythmia amiodarone, other rate-limiting substances beta-blockers, calcium-channel blockers (not dihydropyridines) Digoxin tachyarrhythmia Each antiarrhythmic agent that prolongs the repolarization (z. B. procainamide, disopyramide) quinidine orthostatic hypotension Most antihypertensives (rarely beta blockers) antipsychotics (mainly phenothiazines) doxorubicin Levodopa loop diuretics, nitrates (with or without phosphodiesterase inhibitor for the treatment of erectile dysfunction) quinidine Tricyclic antidepressants vincristine Assessment The assessment should be done as soon as possible after the event. The further the syncopal event is back, the more difficult the diagnosis. Information from eyewitnesses are very helpful and are best taken as soon as possible. History The history of this disease should the events that lead to syncope, determine, including the activity of the patient (eg. As physical activity, armed, in a potentially emotional situation), position (z. B. lying or standing) and when standing, for how long. include important accompanying symptoms immediately before or after the event if there was a sense of an existing LOC, nausea, sweating, blurred vision or tunnel vision, tingling of the lips or fingertips, chest pain or palpitations. The duration of the recovery period should also be determined. Unless there were eyewitnesses, they should be consulted and asked to describe the event, in particular the existence and duration of any seizure symptoms. The system check should ask under effort by any pain or injury areas, episodes of dizziness or pre-syncope after getting up and episodes of palpitations or chest pain. Patients should look for symptoms that define the possible causes suggested are asked, including bloody or tarry stools, severe menstrual (anemia); Vomiting, diarrhea or excessive urination (dehydration or electrolyte abnormalities) and risk factors for pulmonary embolism (recent surgery or immobilization, known cancer, blood clots or hypercoagulability past). The medical history should by previous syncopal events, issues known cardiovascular disease, known seizure disorder. The drugs taken should be identified (in particular antihypertensives, diuretics, vasodilators, and antiarrhythmic agents – see table: Some drug-related causes of syncope). The family history was the incidence of heart disease at a young age or sudden death in a family member notieren.Körperliche examination Vital signs are essential. Heart rate and blood pressure are measured with the patient supine and after 3 minutes of standing. The pulse is sampled according to irregularities. The general study listed the mental state of the patient, including any confusion or indecision, which may indicate a post-ictal state, and any signs of injury (eg. As bruising, swelling, tenderness, tongue bites). The heart is auscultated to sounds. If noise is present, each of their changes with a Valsalva maneuver, standing or squatting is noted. A careful evaluation of the jugular vein waves (Normal jugular vein waves.), While the carotid artery or the heart is scanned auscultation may allow the diagnosis of arrhythmia, if no ECG is available. Some clinicians practicing in the patient in the supine position during ECG monitoring carefully unilateral carotid sinus pressure to detect bradycardia or “heart block”, suggesting carotid sinus hypersensitivity. Carotid sinus pressure should not be applied if a significant flow noise through the carotid artery is present. The abdomen is scanned for tenderness and a rectal examination is performed to check for gross or occult blood. A complete neurological examination is performed to rule out any focal abnormalities that may indicate a CNS cause (eg seizure disorder.) To identifizieren.Warnzeichen Certain findings indicate a more serious etiology out: syncope during exercise Several repetitions within a short time a heart murmur or other findings suggestive of structural heart disease (eg. as chest pain) Seniority significant violations during syncope family history sudden unexpected death, Belastungssynkope or unexplained recurrent syncope or seizures interpretation of the findings Although the cause is often benign, it is important that sometimes to identify life-threatening causes (eg. as tachyarrhythmia conduction block) because sudden death is a risk. The clinical findings (see table: Some causes of syncope) assist in 40-50% of cases, to suggest a cause. A few generalizations are useful. Benign causes often lead to syncope. announced a syncope, preceded by an unpleasant physical or emotional event (eg. as pain, shock), usually occurring in the upright position and frequently by previous vagal mediated warning symptoms (eg. as nausea, fatigue, yawning, blurred vision, sweating) speak for vasovagal syncope. Syncope, which occurs most often when the upright position is occupied (especially in the elderly after a long bed rest or in patients taking the drugs in certain classes), speaks for orthostatic syncope. Syncope that occurs after long standing without moving, usually caused by venous pooling. A LOC that begins suddenly, incontinence, ptyalism or tongue bite is associated with muscle spasms or convulsions that last longer than a few seconds and is followed by postictal confusion and somnolence, speaks for a seizure. Hazardous cases are suspected when serious results are available. Syncope on exertion indicates a cardiac obstruction or triggered by physical activity arrhythmia. Such patients often have chest pain, palpitations, or both. Cardiac findings can assist in identifying the cause. A raw and basal noise with spätsystolischem maximum that radiates into the two carotid arteries, speaks for aortic valve stenosis. A systolic murmur, increases with the Valsalva maneuver and disappears into a squatting position, speaks for hypertrophic cardiomyopathy. Syncope that begins suddenly and spontaneously ends, is typical of cardiac origin, most often by an arrhythmia. Syncope while lying also indicates arrhythmia because vasovagal and orthostatic mechanisms cause syncope in the lying position. Syncope with injury during an episode increases the likelihood of a cardiac cause or a seizure something and therefore the event triggers severe misgivings. Warning signs and slower LOC that accompany benign vasovagal syncope, the likelihood of injury slightly reduce. Tests are typically conducted tests. ECG pulse oximetry Sometimes Sometimes echocardiography tilt-table testing blood tests only when clinically indicated CNS imaging is rarely indicated. In general, is carried out (especially in a short time), more intensive investigation if syncope resulting in an injury or recurs. Patients with suspected arrhythmia, myocarditis or ischemia should be investigated stationary. Other patients can be examined on an outpatient basis. A EKGwird in all patients performed. The ECG can detect arrhythmias, a change in the excitation line, a ventricular hypertrophy, Präexzitationen, QT prolongation, pacemaker dysfunction, myocardial ischemia or myocardial infarction. If no clinical clues are present, it is wise to measure cardiac enzymes to write serial ECGs to exclude a myocardial infarction in the elderly, as well as record a Holter monitor for at least 24 hours. Each detected arrhythmia must be reconciled with an altered state of consciousness to be regarded as the cause. but most patients have no events during the monitoring. On the other hand, the presence of symptoms in the absence of cardiac arrhythmias helps exclude cardiac causes. An event recorder can be helpful if preceded by warning symptoms of syncope. A signal-averaged ECG can detect a predisposition to ventricular arrhythmias in patients with ischemic heart disease or after myocardial infarction. If the syncopal episodes irregularly done (eg. As <1 month), an implantable loop recorder can be used for long-term recording. During or immediately after an event a pulse oximeter should be connected to detect a hypoxemia (which can display a pulmonary embolism). If hypoxemia present, CT or lung scan is indicated in order to prevent pulmonary embolism. Laboratory tests are performed based on clinical diagnosis. Laboratory values ??reflexively raised are of little use. For all women of childbearing age, however, a pregnancy test is performed. Hkt if anemia is suspected is measured. Electrolyte to be measured, when an abnormality (for. Example, by taking symptoms or substance) is suspected clinically. Troponin i. P is measured when acute MI is suspected. Echocardiography is indicated in patients with stress-induced syncope, heart sounds and for suspected intracardiac tumors (eg. As those with positional syncope). A Kipptischversuch can be performed if the history or physical examination for a vasodepressor or reflex induced syncope speaks. It is also used in the study of exercise-induced syncope when the echocardiogram or stress test was negative. Stress tests (physically or pharmacologically) are then performed when a transient myocardial ischemia is suspected. They are often performed in patients with symptoms that are induced by physical exercise. The invasive electrophysiology is then taken into account when the non-invasive tests can not explain the arrhythmia in patients with unexplained syncope. A negative result defines a subgroup with a low risk and a high rate of remission of the syncope. The use of elektrophysiolgischen investigation is controversial in other patients. A stress test is less useful, unless a physical activity preceded the syncope. EEG is justified if a seizure disorder is suspected. CT and MRI of the head and brain are indicated only if indicate the signs and symptoms of a focal CNS disorder. Treatment If syncope observed werdem immediately checked pulses immediately. If the patient has no pulse, cardiopulmonary resuscitation is performed. When pulses are present, severe bradycardia is treated with atropine or external transthoracic stimulation. Orciprenalin can be used to maintain an adequate heart rate, while a temporary pacemaker are placed. (Editor's note: In Germany, normally used Orciprenalin.) Tachyarrhythmias are treated. A DC-synchronized shock is faster and more secure in unstable patients. Insufficient venous return flow by the patient is kept in a supine position is treated, the legs are lifted and i.v. will be normal saline. Tamponade is relieved by pericardiocentesis. Spannungspneumothorax requires the insertion of a Pleurakanüle and drainage. Anaphylaxis is treated with parenteral adrenaline. If the patient is brought to a syncope in the supine position with legs elevated, typically the syncopal phase ends, provided life-threatening diseases are ruled out. If the patient sits up too quickly may recur syncope; the upright storage of the patient and the transport of the patient in the upright position can extend the cerebral perfusion and prevent recovery. The specific treatment depends on the cause and pathophysiology. Central geriatric aspects The most common cause of syncope in older patients is orthostatic hypotension due to a combination of factors. The factors include rigid, non-compliant arteries, reduced skeletal muscle pumps of the venous return by physical inactivity and degeneration of the sinoatrial node and the conduction system through a progressive structural heart disease. When elderly syncope often has more than one cause. For example, the combination of the capture of several heart and blood pressure medications with standing in a hot church during a long and emotional exhibition lead to syncope, although no single factor could cause syncope. Summary syncopation resulting from global CNS dysfunction, usually from insufficient cerebral blood flow. Most syncope resulting from benign causes. Einige weniger häufige Ursachen umfassen Herzrhythmusstörungen oder -ausflussobstruktion. Diese sind ernstzunehmend oder potenziell tödlich. Die vasovagale Synkope hat in der Regel einen ersichtlichen Auslöser, Warnzeichen und nur wenige Minuten oder länger von Symptome nach der Besserung. Synkopen aufgrund von Herzrhythmusstörungen treten typischerweise abrupt und mit rascher Erholung auf. Krampfanfälle haben eine verlängerte (z. B. Stunden) Erholungsphase. Wenn eine benigne Ursache nicht klar ist, sollte Autofahren und der Einsatz von Maschinen untersagt sein, bis die Ätiologie bestimmt und behandelt wird - die nächste Manifestation einer unerkannten kardialen Ursache könnte tödlich sein.

Comments

Leave a Reply

Sign In

Register

Reset Password

Please enter your username or email address, you will receive a link to create a new password via email.