THE COMPREHENSIVE GUIDE TO SYNCOPE

7 min


INTRODUCTION:

The term syncope is often known by other names like fainting, blacking out, passing out, swooning, etc. According to Malamed, syncope defined as the transient loss of consciousness associated with the inability to maintain postural tone. This occurs due to decreased blood flow to the brain results in decreased blood glucose level, which occurs due to abnormal heart rhythms triggered by underlying heart problems, severe dehydration or injuries.

Almost 53% of syncopes reported as medical emergencies. Nearly one-third of the population have signs of syncope. Hence, every one of us should be aware of managing these kinds of emergencies. Similarly, fainting is different from seizure, and this also differs from person to person. Therefore, let’s understand syncope and how it differs from other similar conditions.

OTHER NAMES OF SYNCOPE:

There are various names for syncope. Some of them include,

  • Atrial bradycardia
  • Simple faint
  • Benign faint
  • Neurogenic syncope
  • Vasovagal syncope
  • Vasodepressor syncope
  • Swoon
  • Neurogenic syncope
  • Psychogenic syncope.

HISTORY:

The term fainting has a past. In the year 1744, Pietro Longhi drew an oil painting called fainting. In the painting, a woman in a pink gown seems to be sick and she sinks back pretending to faint. Meanwhile, her servants and companions surround her. However, the man probably a doctor, identifies the truth that she’s not sick. Subsequently, this might be the reason behind the term ‘fainting’.

PREDISPOSING FACTORS FOR SYNCOPE:

There are two groups of factors which predispose to syncope they are:

PSYCHOGENIC FACTORS:

  • Fright (Fight or flight response)
  • Anxiety
  • Emotional stress
  • Receiving unwelcomed or unpleasant news
  • Pain, especially sudden and unexpected
  • The sight of blood in any incidents or procedures.

NON PSYCHOGENIC FACTORS:

  • Sitting or standing for a long time, standing up too fast
  • Overheating
  • Emotional upset or stress
  • Missing a meal or feeling hungry (from diets)
  • Exhaustion
  • Impaired physical health
  • Humid environment
  • Men aged between 16 and 35 years.

PRE SYNCOPAL SIGNS AND SYMPTOMS:

EARLY:

  • Feeling warm
  • Loss of colour, pale or ash grey skin tone.
  • Heavy perspiration (diaphoresis ,so called heavy sweating)
  • Nausea
  • Lowered blood glucose level
  • Tachycardia (increased heart rate)

LATE SYMPTOMS:

  • Pupillary dilation
  • Yawning
  • Hyperapnoea
  • Cold hands and feet
  • Hypotension
  • Bradycardia
  • Dizziness
  • Visual disturbances
  • Loss of consciousness

TYPES OF SYNCOPE:

Firstly, syncope is classified into four types namely:

REFLEX SYNCOPE:

Otherwise called neurally mediated syncope, it occurs when a certain type of reflexes are not properly regulated. This type of syncope results in decreased blood flow to the heart reduces the blood glucose level, hence decreases blood flow to the brain.

Further, there are three types of reflex syncope,

VASOVAGAL:

This type of syncope results when the body overreacts to the trigger response. Moreover, the trigger response includes intense pain, standing too long etc. Meanwhile, this type of syncope results in 50% of fainting.

SITUATIONAL:

To clarify, as the name implies this occurs in situations like laughing, coughing, swallowing etc.

CAROTID SINUS:

This type of fainting occurs due to pressure created by the carotid artery around the neck. Further, the common causes are tight collars around the neck, tight clothing’s surrounding the neck etc.

CARDIAC SYNCOPE:

Cardiac problems are the main cause of these problems . Almost 15 % of cases fall under this type.

The causes include cardiac ischemia (ischemia refers to reduced oxygen supply to the heart), heart valve disorders, arrhythmias, etc. However, this usually occurs in older aged people above 60 years with a history of heart disease. The symptoms are chest pain before fainting while exercising while laying down. Importantly, diagnosing this type of syncope at the earliest is good. It may rarely lead to shock.

ORTHOSTATIC SYNCOPE:

Firstly, this occurs due to a sudden drop in blood pressure while standing. Further, this sudden drop in pressure occurs due to the effects of gravity. This occurs due to severe dehydration (vomiting or diarrhoea), carotid stenosis, steal syndrome (reversal of blood flow in basilar arteries)

CEREBRO VASCULAR SYNCOPE:

This type of fainting results due to associated with the blood vessels in and around the brain this results in decreased blood supply level to oxygen.

OTHER TYPES OF SYNCOPE REPORTED:

COUGH SYNCOPE:

This type, more common in middle-aged men overweight with obstructive airway disease. Hence, these types of patients have increased intrathoracic pressure. The exact mechanism of this type of syncope not known. Recently they have found in a study that neurally mediated reflex bradycardia reflex mechanism, creates a response to cough. Loss of consciousness results in direct stimulation of cough, and so the resultant stimuli result in recurrent fainting episodes. Therefore, these patients faint after continual coughing. Therefore, the patients should be handled with a lot of care, and the underlying cause should be treated. In older days known as laryngeal vertigo and now termed cough syncope.

PEDIATRIC SYNCOPE:

This type occurs in children younger than 18 years of age. Almost 15% of cases associated with this type. The causes include severe dehydration, recurrent episodes of seizures, etc.

ELDERLY SYNCOPE:

This type is more prevalent in elderly people. It occurs due to orthostatic hypotension (OH) in elderly people. To clarify, Orthostatic hypotension is a condition in which sustained reduction of blood pressure atleast 20mm hg  or diastolic pressure 10 mm hg within 3 minutes of standing . Other conditions like post prandial hypotension, cardiac disorders , these conditions lead to syncope in elder people.

DIAGNOSTIC TEST USED TO DETECT SYNCOPE:

Taking a proper medical history, syncope has been diagnosed by the doctor, the following test referred by the doctor they are:

ELECTROCARDIOGRAM (ECG):

ECG defined as the recording of the electrical activity of the heart. To clarify, it is a simple, painless procedure. An electrocardiogram is a graph that records cardiac activity. And also, it gives information about the rate and rhythm of the heart. Hence, it is known as the gold standard test to diagnose various heart conditions like hypertrophies, ischemia, infarction, arrhythmias, etc. Further, it helps to detect the electrolyte activity of the heart.

LABORATORY TEST:

Blood test detects the infection in blood. And conditions like diabetes, anaemia etc.

TILT-TABLE TEST:

A tilt table test used to evaluate the cause of unexplained fainting. It is a non-invasive procedure. To clarify it in simple words, this involves changing a person’s position quickly and seeing how their blood pressure and heart rate response. This test indicated for neutrally mediated syncope. This test assesses the cause of syncope and underlying associated cardiac conditions.

STRESS TEST:

This test measures the heart’s ability to respond to external stress (in a clinically controlled environment). To check the heart activity during physical activity. This test reveals the blood flow to the heart.

IMAGING:

This test includes Computed tomography (CT scan), MRI (Magnetic resonance imaging), to capture the image. Therefore, a CT scan is faster and provides pictures of the internal organs. Magnetic resonance produces more quality images determines abnormal tissues.

MANAGEMENT OF SYNCOPE:

STEP 1: POSITION

In the first step, the patient should be placed immediately in the supine position, and the legs should be raised by taking others’ help. The legs are raised to prevent bending which improves oxygen supply to the brain. This is called Trendelenburg’s position. More commonly in dental procedures like extraction, patients become unconscious. During these situations the patient should be placed in the supine position, the dental procedure should be terminated. Steps should be taken to make the patient conscious.

STEP 2 : CIRCULATION- AIRWAY- BREATHING

The victim should be assessed immediately and a patent airway should be established. Any hindrances to the airway should be removed. To maintain a patent airway, a chin lift procedure should be done. The adequacy is assessed through the look-listen-feel technique. This is to assess the carotid pulse, which should be palpated by placing three fingers inside of the neck. Therefore we call this procedure a basic medical support procedure, C-A-B ( circulation- airway- breathing) should be checked and call for an ambulance.

STEP 3: DEFINITIVE CARE:

This step will be carried in hospitals. Administration of oxygen and vital signs should be monitored. Other additive procedures such as placing aromatic ammonia vapours under the nose, administration of sugar, or any sort of orange juice or non-diet soft drinks play a crucial role in increasing the blood glucose level. The drug atropine is administered if bradycardia still persists.

PREVENTING SYNCOPE:

  • Firstly, the important thing is to keep yourself hydrated, to prevent dehydration. The main reason for dehydration is electrolyte depletion.
  • Do not skip, avoiding or fast for long period. Further, these reduce our energy level.
  • Some external factors include the sight of blood, getting a shot, or intense pain. Further. try to avoid these situations if possible
  • Avoid wearing shirts with tight collars, this pressurizes the neck region resulting in fainting. Further, wear loose clothes during summer.
  • Stand up slowly, getting up too quickly can cause blood pressure to drop. Meanwhile this prevents enough blood flow from flowing through the brain.

CONCLUSION:

To sum up, stay hydrated do not skip meals, consume lots of fruits which improves the water content of the body. Further, exercising or doing any sort of physical activity every day is very important for us to stay healthy. Everyone should be aware of this life-saving procedure, at least we should know to raise the victim’s leg to maintain Trendelenburg position, and give sugar to recover the patient before arranging for medical services. Further, not only medical professionals but every common people should know this life-saving procedure.


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Dr Shalini S.G
I am a dental surgeon. I love travelling and listening to music and a passionate person in research and doing lots of presentation. My area of interest is pathology, diagnosis and forensics.