Loss of Consciousness/Syncope

Loss of Consciousness (LOC)

• DDX:
  • – Seizure, grand mal
    
  • – Vasovagal
    
  • – Cardiac arrhythmia
    
  • – Drug/orthostatic
    
  • – Convulsive syncope
    
  • – Aortic stenosis
• Physical Exam:
  • – VS: State (or WNL or WNL except…) (no orthostatic changes)
  • – General: Patient is in no acute distress
  • – HEENT: Inspect head, mouth, carotid auscultation and palpation, thyroid exam
    • – NC/AT, PERRLA, EOMI without nystagmus, no papilledema, no cerumen, TMs normal, mouth and oropharynx normal
  • – Neck Exam: Carotid auscultation
    • – Supple, No carotid bruits, 2+ carotid pulses with good upstroke bilaterally, thyroid normal
  • – Chest Exam: Auscultation
    • – Clear breath sounds bilaterally
  • – Heart Exam: Palpation, Auscultation (orthostatic vital signs)
    • – Apical impulse not displaced, RRR, S1, S2 wnl, No murmurs, rubs, or gallops heard
  • – Extremities: Palpated peripheral Pulses Symmetric, brachial, radial, and dorsalis pedis pulses bilaterally
  • – Neuro Exam: Cranial nerves (including fundoscopic exam), Motor exam, DTRs, cerebellar, Romberg sign, gait, sensory exam
    • – CN 2-12 intact grossly; Motor: Strength 5/5 in all muscle groups; Sensation: Intact to pinprick and soft touch; DTRs, symmetric 2+ in upper and lower extremities, (-) babinski bilaterally; Cerebellar: (-) Romberg, finger to nose normal; Gait: Normal
• Work-up:
  • – CBC with diff
    
  • – Electrolytes
    
  • – Glucose
    
  • – Urine Toxicology (Urine Tox)
    
  • – EEG
    
  • – MRI
    
  • – CT
    
  • – Lumbar Puncture (LP)
    
  • – ECG

Aortic Stenosis

• Presentation:
  • – Commonly exertional or postecertional and occur w/o warning
  • – Shortness of breath
    
  • – Anginal chest discomfort
    
  • – Family history of AS
  • – Age 60 and up
    
• Physical Exam/Vital Signs:
  
  • – Narrow pulse pressure
    
  • – Displaced PMI

Cardiac Arrhythmia

• Causes:
  • – Cardiac syncope typically occurs w/o warning, although a history of palpitations may indicate the presence of underlying arrhythmias
  • – MI/Stroke = Increased risk for developing ventricular tachycardia
  • – Beta-blockers can contribute to bradyarrhythmia
• Presentation:
  • – Palpitations
  • – Chest discomfort
  • – Shortness of breath
  • – Medication history
• Physical Exam/Vital Signs
  • – Abnormal heart rate
  • – Irregular heartbear
• DDX:
  • – Cardiac Arrhythmia (causing syncope)*
    
  • – Severe aortic stenosis
    
  • – Syncope (other causes)
    
  • – Seizure
    
  • – Pulmonary embolism
• Work-up:
  • – ECG
    
  • – Holter monitoring
    
  • – CBC with diff, Electrolytes, Glucose
    
  • – Echocardiography
    
  • – CT—head

Convulsive Syncope

• Presentation:
  • – Seizure-like activity often occurs after syncope and is due to global cerebral hypoperfusion
    
  • – There is no EEG correlate and seizure w/u is not required

Drug-Induced Orthostatic Hypotension 

• Presentation:
  • – Anti-hypertensive meds, diuretics, etc. can cause orthostatic hypotension and syncope
    
  • – However, lightheadedness and syncope in this condition is usually postural (i.e., occurs when getting up from a lying or seated position), and this patient’s orthostatic vital signs were normal
• DDX:
  • – Drug-induced orthostatic hypotension (causing
    syncope)
    
  • – Cardiac arrhythmia
    
  • – Syncope (vasovagal, other causes)
    
  • – Stroke
    
  • – MI
    
  • – Pulmonary embolism
• Work-up:
  • – Orthostatic Vital Signs
    
  • – CBC with diff, Electrolytes
    
  • – CT—head
    
  • – ECG
    
  • – V/Q Scan
    
  • – CTA—Chest with IV contrast

Hypertrophic Cardiomyopathy

• Presentations:
  • – Commonly exertional or postecertional and occur w/o warning
    
  • – Palpitations
    
  • – Dizziness
    
  • – Shortness of breath
    
  • – Younger athlete
    
  • – Family history
    
  • – Occurs with exercise
• Physical Exam:
  
  • – Heart Murmur

Orthostatic Hypotension

• Causes:
  
  • – Alcohol ingestion
    
  • – Medication as cause
    
  • – Dehydration
    
• Presentation:
  
  • – Tachycardia
    
  • – Hypotension when standing
    
  • – Advanced age

Seizure

• Presentation:
  • – falling and losing consciousness
  • – rhythmic movements of the limbs, tongue biting, and lost control of bladder. subsequently confused 
  • – Seizures usually occur unpredictably in a manner unrelated to posture or exertion
  • – May stem from a variety of causes, including metabolic factors, trauma, vascular factors, and brain tumors
  • – Tonic -clonic seizures are often accompanied by tongue biting, incontinence, and prolonged confusion or drowsiness postictally
• Seizure Types:
  • Partial Seizures (Produced by a small area of the brain)
    1. Simple (awareness is retained)
       1. Simple Motor = Jerking, muscle rigidity, spasms, head-turning
       2. Simple Sensory = Unusual sensations affecting either the vision, hearing, smell taste, or touch
       3. Simple Psychological = Memory or emotional disturbances
    2. Complex (Impairment of awareness) = Automatisms such as lip smacking, chewing, fidgeting, walking and other repetitive, involuntary but coordinated movements
    3. Partial seizure with secondary generalization = Symptoms that are initially associated with a preservation of consciousness that then evolves into a loss of consciousness and convulsions.
  • Generalized Seizures (Produced by the entire brain) – 6 Types
    1. “Grand Mal” or Generalized tonic-clonic = Unconsciousness, convulsions, muscle rigidity
    2. Absence = Brief loss of consciousness
    3. Myoclonic = Sporadic (isolated), jerking movements
    4. Clonic = Repetitive, jerking movements
    5. Tonic = Muscle stiffness, rigidity
    6. Atonic = Loss of muscle tone
• DDX:
  • – Seizure, grand mal (now called complex tonic-clonic seizure)
  • – Convulsive syncope
    
  • – Substance abuse/overdose
    
  • – Malingering
    
  • – Hypoglycemia
• Work-up:
  • – CBC with diff, Electrolytes, Glucose
    
  • – Urine Toxicology
    
  • – EEG
    
  • – MRI—brain
    
  • – CT—head
    
  • – LP—CSF analysis
    
  • – ECG

Vasovagal Syncope

• Presentation:
  • – Syncope is often heralded by nausea, sweating, tachycardia, pallor, and feeling “faint” (same mechanism as posmicturation syncope)
  • – Emotional, Stressful situation/Pain ( may be due to excessive vagal tone with resulting hypotension)
    
  • – Quick recovery in minutes
    
  • – No seizure activity
• Physical Exam: 
  • – Normal vital signs (when recovered)