Suggestion:
Syncope (also called staggered axis) is a temporary loss of consciousness caused by cerebral ischemia and hypoxia. Syncope is different from coma, which takes a long time to lose consciousness and is difficult to recover. The difference between syncope and shock lies in the unconscious disorder in the early stage of shock, and the signs of peripheral circulation failure are obvious and lasting. Patients with syncope can not be ignored and should be treated in time.
Concurrent syndrome
1. Patients with obvious autonomic nervous dysfunction (such as pale face, cold sweat, nausea, fatigue, etc. ) more common in vasoinhibitory syncope or hypoglycemia syncope.
2. Paleness, cyanosis and dyspnea are seen in acute left heart failure.
3. There are obvious changes in heart rate and rhythm, which can be seen in cardiogenic syncope.
4. Convulsion patients are found in central nervous system diseases and cardiogenic syncope.
5. Those accompanied by headache, vomiting and hearing loss suggest central nervous system diseases.
6. With fever, edema and clubbing, it indicates heart and lung diseases.
7. Patients with shortness of breath, numbness of hands and feet and convulsions are found in hyperventilation syndrome and hysteria.
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Key points of consultation
1. Age and sex of syncope.
2. The inducement of syncope attack, the relationship between attack and body position, cough and urination, and drug treatment.
3. The occurrence speed, duration, complexion, blood pressure and pulse of syncope.
4. Symptoms related to syncope are as described above.
5. Have a history of cardiovascular and cerebrovascular diseases.
6. Have the same history of seizures and family history in the past.
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disadvantaged groups
Both men and women get sick.
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complication
Orthostatic hypotension syncope
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classify
At present, there are many different views on the classification of syncope, and the names of various types of syncope are also controversial. More reasonable table classification. Non-cardiogenic syncope is more common, but cardiogenic syncope is more serious.
First, cardiogenic syncope
1. Arrhythmia
① Bradycardia: bradycardia, cardiac arrest, sick sinus syndrome, cardiac block, etc.
② tachyarrhythmia: paroxysmal supraventricular tachycardia, ventricular tachycardia, etc.
③ Long QT syndrome
2. Organic heart disease
① Acute cardiac output is blocked.
Left ventricular outflow tract obstruction: aortic stenosis, left atrial myxoma, valve thrombosis, etc.
Right ventricular outflow tract obstruction: pulmonary valve stenosis, primary pulmonary hypertension, pulmonary embolism, etc.
② Myocardial lesion and congenital heart disease: acute myocardial infarction, tetralogy of Fallot, etc.
Second, syncope caused by non-cardiac factors.
1. Nerve-mediated syncope
① Vasovagal syncope
② Carotid sinus hypersensitivity syndrome
③ Situational syncope: cough syncope, micturition syncope and swallowing syncope.
④ Painful syncope
2. Postural hypotension
3. Cerebral syncope
① Cerebrovascular diseases: diffuse sclerosis of cerebral arteries, transient ischemic attack, etc.
② Cerebral vasospasm
③ Takayasu arteritis, subclavian artery stealing blood.
④ Cardiovascular central lesion of medulla oblongata
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4. Syncope caused by abnormal blood composition
① Hypoglycemia syndrome
② Anemia
③ Hyperventilation syndrome
④ High altitude or hypoxic syncope.
5. Syncope caused by mental illness: hysteria, anxiety neurosis, etc.
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clinical picture
1. If syncope occurs in sitting position or upright position with obvious inducement, consider vasoinhibitory syncope (simple syncope) or postural hypotension. The former is mostly caused by emotional tension, fear, pain and fatigue. And there are often short-term precursor symptoms before fainting; The latter often stands up suddenly after standing for a long time or squatting for a long time. Some people are weak or have no prodromal symptoms after taking hibernating spirit and antihypertensive drugs.
2. Carotid sinus syndrome should be considered if syncope is induced by sudden head turning or collar tightening, accompanied by convulsions, slow heart rate and slight drop in blood pressure.
3. Syncope occurs after a severe cough or when you wake up to urinate during sleep. Consider coughing or urinating syncope.
4. When syncope occurs during exertion, severe anemia, aortic stenosis or primary pulmonary hypertension should be considered.
5, syncope with arrhythmia, cyanosis, pale face, angina pectoris, consider cardiogenic syncope. Such as acute cardiogenic cerebral ischemia syndrome, complete atrioventricular block, paroxysmal tachycardia, atrial fibrillation, ventricular fibrillation, cardiac arrest and myocardial infarction. If syncope or epileptic convulsion occurs repeatedly and there are signs of mitral stenosis, left atrial myxoma or left atrial giant thrombosis should be considered, and syncope often occurs when posture changes.
6. Syncope is accompanied by numbness, hemiplegia, hemianopia, language disorder and other symptoms. Consider transient ischemic attack.
7. Syncope has a history of insomnia, dreaminess, forgetfulness and headache. Consider neurasthenia and chronic lead poisoning encephalopathy.
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diagnose
Syncope, as a common clinical syndrome, has a certain disability rate and mortality. Therefore, it is of great significance to diagnose and treat this kind of patients as soon as possible. But in many cases, the diagnosis of syncope patients is not easy. A detailed understanding of the patient's medical history, careful physical examination (including blood pressure measurement) and electrocardiogram examination are the three basic elements for diagnosing syncope and judging its causes. Other laboratory and instrument inspections are also necessary.
Diagnosis and differentiation
First, medical history problems syncope often suddenly loses consciousness, falls, pale face, cold limbs, no convulsions, tongue biting, urinary incontinence. You should ask about the situation before syncope, whether there are signs, the degree and duration of consciousness disorder during syncope, and whether there were pale face, slow pulse, urinary incontinence, limb convulsions, etc. Syncope often has stimulating factors such as sadness, fear, anxiety, fainting, seeing blood, trauma, severe pain, sultry and fatigue. Urination, defecation, cough, blood loss and dehydration can also be incentives; We should know the body position and head position when attacking. When we change from lying position to standing position, we often have orthostatic hypotension syncope, and when the head position suddenly turns, we often have allergic syncope of carotid sinus.
Second, the physical examination found that cardiogenic syncope often has heart valve disease, arrhythmia, myocardial ischemia and other reasons, and heart auscultation may have heart murmur and arrhythmia; Syncope caused by insufficient blood supply to the cervical and vertebral arteries is often found that the pulsation of one carotid artery is weakened or disappeared, and abnormal vascular murmurs can be heard, and syncope occurs during neck turning and head-up test; Syncope caused by brainstem diseases often has brainstem signs such as cross paralysis, cross or dissociative sensory disturbance; Pulse-free and subclavian steatosis, often accompanied by hypotension in one upper limb, audible murmur in neck and supraclavicular fossa; The blood pressure difference of three postures (lying, sitting and standing) measured by primary orthostatic hypotension is ≥50mmHg.
Third, ECG auxiliary examination and cardiac B-ultrasound examination are suitable for cardiogenic syncope. Head CT, cerebral angiography, cerebrospinal fluid examination, cervical X-ray, carotid artery and vertebral artery B-ultrasound examination are suitable for cerebral syncope. How normal the EEG is.
Imaging diagnosis
Electrocardiogram and echocardiography are suitable for cardiogenic syncope. Head CT, cerebral angiography, cerebrospinal fluid examination, cervical X-ray, carotid artery and vertebral artery B-ultrasound examination are suitable for cerebral syncope. How normal the EEG is.
Medical history and routine examination
About 45% patients with syncope can be diagnosed by medical history and physical examination. The medical history can help the doctor to determine that the patient belongs to syncope attack and provide some information that is helpful for diagnosis and differential diagnosis. When collecting medical history, we should pay attention to past history, inducing factors, precursor symptoms, body position, duration, accompanying symptoms, recovery, family history and so on.
Inducing/inducing factors
Vasovagal syncope should be considered first after contact with sudden fear, pain or unpleasant images, sounds and other events or after standing weakly for too long. Attention should be paid to carotid sinus allergy when syncope is induced by turning head or pressing carotid sinus. Syncope caused by postural hypotension is often induced by sudden standing in lying or squatting position. Situational syncope is induced by special circumstances such as cough and urination. Fatigue, tension or exertion often induce cardiogenic syncope, but well-trained athletes without heart disease should pay attention to the possibility of vasovagal syncope after exercise. If syncope occurs after changing body position (bending over, turning over, etc.). ) accompanied by heart murmur, which may be atrial myxoma or thrombosis. Patients with syncope after upper limb activity should pay attention to subclavian artery stealing or aortic dissection if they find asymmetry of blood pressure or pulse in both upper limbs.
Precursor symptoms and body position
Before the attack of vasovagal syncope, there are often symptoms of vagus nerve excitement such as dizziness, weakness of limbs, cold sweat and pallor. Situational syncope usually has no prodromal symptoms or brief dizziness, and then loses consciousness. Syncope caused by cardiogenic syncope and extensive cerebrovascular sclerosis often has no obvious precursor symptoms. Syncope caused by hypertensive encephalopathy, with severe headache and vomiting before onset. Hypoglycemia hyperventilation syncope has a long prodromal period, characterized by dizziness and fatigue, and sweating is obvious when hypoglycemia occurs. Hypoglycemia, hyperventilation and most cardiogenic syncope have nothing to do with body position. Syncope caused by postural hypotension occurred shortly after the patient stood up from supine position. Reflex syncope mostly occurs in sitting or standing position.
period
Reflex syncope lasts for the shortest time, only a few seconds. Syncope induced by hyperventilation and hypoglycemia usually lasts for several minutes and develops gradually. Syncope caused by coronary heart disease lasts for a long time. The loss of consciousness caused by aortic stenosis can be as long as 10 minutes. For patients with short-term, asymptomatic and heart disease, arrhythmia should be considered first.
Concurrent syndrome
When postural hypotensive syncope occurs, the systolic blood pressure can be lower than 60mmHg. Painful syncope is often accompanied by facial or throat pain. Cardiogenic syncope is often accompanied by cardiovascular signs such as arrhythmia, decreased blood pressure, cyanosis and dyspnea. There may also be a brief limb twitch. Patients with cerebral syncope often show signs of nervous system damage such as aphasia and hemiplegia. Patients with hyperventilation often have numbness or tingling in their hands and faces. Recurrent syncope without heart disease but with a variety of physical discomfort usually stems from mental illness.
Recover after an attack
Reflex syncope recovered quickly after the attack, and several of them were temporarily weak. Cardiogenic syncope often appears chest tightness, shortness of breath and fatigue; Severe dyspnea and angina pectoris; In extreme cases, sudden death will occur.
Past medical history and family history
Patients with syncope who have a family history of syncope or sudden death should pay attention to the possibility of long QT syndrome, hypertrophic cardiomyopathy or WPW syndrome. Elderly patients with syncope should pay special attention to their medication history, especially when changing medicine and taking new drugs.
physical examination
Patients with syncope should immediately measure their pulse, heart rate and blood pressure, and pay attention to whether they have pallor, dyspnea and peripheral varicose veins. Pay special attention to the examination of postural hypotension, blood pressure of both upper limbs and signs of heart and brain system. The orthostatic blood pressure should be measured after the patient lies flat for 5 minutes and stands up for 3 minutes.
Some special medical history, symptoms or signs often suggest the possibility of some type of syncope. Table 3 summarizes some clinical features that are helpful to patients with syncope.
Auxiliary inspection and special inspection
Generally speaking, all patients with syncope are advised to have an electrocardiogram examination. It is generally difficult to obtain meaningful information from blood electrolytes, blood routine tests and liver and kidney function tests of patients with syncope, and unless the medical history and physical examination suggest that there may be problems with the above indicators, they will not be used as routine tests. For those who are suspected of cardiogenic syncope but can't find abnormality by routine electrocardiogram, ECG and echocardiography should be monitored to understand the heart condition. If arrhythmia is suspected and ECG monitoring is not positive, electrophysiological records of intracardiac stimulation can be used. About 2/3 patients developed ventricular tachycardia, bundle branch block, atrial flutter and sick sinus syndrome during stimulation. This method has special value for patients with ischemic heart disease and previous myocardial infarction. Those who seem to have abnormal autonomic nerve function can be examined for autonomic nerve function. If organic nervous system diseases are suspected, EEG, skull CT or MRI should be done to clarify the nature of central nervous system diseases. For patients suspected of pulmonary insufficiency and hypoglycemia, arterial blood gas and blood sugar should be detected.
If the patient with recurrent syncope has no spontaneous attack between two attacks and the diagnosis is not clear, the induced attack can be considered. Some syncope can often be diagnosed by recurring attacks, such as carotid sinus allergy, postural hypotension and cough syncope (Valsalva maneuver: exhaling when the glottis is closed). Patients with hyperventilation and syncope can take a quick deep breath for 2-3 minutes to induce syncope. This operation also has therapeutic value. When patients understand that symptoms can be produced or alleviated at will only by controlling breathing, anxiety as the basis of the disease can be improved to some extent. Under the above circumstances, the most important thing is not whether the symptoms can be induced (the above operations can often induce symptoms in healthy people), but whether the symptoms that appear during spontaneous attacks are indeed reproduced in artificial attacks.
Head-up tilt table test (HUT) is of great significance for the differential diagnosis of syncope, especially for cases with recurrent heart disease. Simple vasovagal syncope with definite diagnosis does not need this test. The principle is that when standing up from supine position, the venous volume increases, the ventricular preload decreases, the cardiac output decreases, the tension of baroreceptors in aortic arch and carotid sinus decreases, the afferent tension of vagus nerve decreases, and the efferent tension of sympathetic nerve increases. Therefore, the normal person's reaction is a slight increase in heart rate, a slight decrease in systolic blood pressure, a slight increase in diastolic blood pressure, and a constant average arterial pressure. In nerve-mediated syncope, the sudden decrease of blood flow back to the heart can lead to a high contraction state in which the ventricle is almost completely emptied, and then the mechanical receptor C fiber located in the lower posterior wall of the left ventricle is excessively excited, and the afferent signal of the vagus nerve is enhanced, resulting in the contradictory heart rate reduction of the nerve center, peripheral vasodilation and hypotension. The operation was performed at 9- 12 am. On an empty stomach, the patient lay flat on the test bench 15 minutes, and recorded ECG, blood pressure and heart rate at the same time. Then tilt the back of the head upwards for 60-80o, and keep it for 30-45 minutes or until the symptoms of pre-syncope or syncope such as bradycardia and blood pressure drop appear. At the beginning of the experiment, using some drugs at the same time can improve the positive rate of the experiment, but it has some influence on the specificity. Such as procainamide and isoproterenol. In particular, sublingual nitroglycerin 0.3mg is convenient and well tolerated, especially for the elderly and patients with coronary heart disease, and it is recommended. After the test, continue lying down until the symptoms disappear. Patients with aortic stenosis, left ventricular outflow tract stenosis, mitral stenosis, proximal coronary artery disease and severe cerebrovascular disease should avoid tilt table test.
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differential diagnosis
Syncope is not difficult to distinguish from dizziness, fall attack and other symptoms. However, both epilepsy and syncope have temporary loss of consciousness, which is sometimes easily confused in clinic. In many cases, EEG can be used to distinguish whether patients have epileptic discharge or sharp wave or slow wave. If there is no abnormality in EEG, it is difficult to diagnose, and sometimes eyewitness description is very important. Refer to the following clinical features:
Limb spasm
① Limb spasms of epileptic patients occur before or at the same time as loss of consciousness, and are divided into tonic phase and clonic phase. The spasm lasted for a long time. However, the convulsion of syncope patients occurred more than 10 minutes after the loss of consciousness, which appeared in the form of general spasm and lasted for a short time.
burst out
② grand mal has nothing to do with posture change and situation, regardless of occasion and time. Loss of consciousness induced by pain, exercise, urination, emotional stimulation, special posture, etc., often suggests syncope.
Symptoms such as sweating and nausea appear.
③ Intermittent loss of consciousness with symptoms such as sweating and nausea usually indicates syncope rather than epilepsy.
A vague state of consciousness
(4) after the attack, there is often a state of confusion, ranging from a few minutes to several hours. Some patients are drowsy or insane after the attack. How quickly consciousness recovers after syncope attack? There are few mental disorders.
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Health care and prevention
Life should be regular, philosophical, don't stay up late, and don't eat three meals a day irregularly. This can make the body's biological clock run regularly, and at the same time make the nerves and body fluids adjust orderly. This is the key to disease prevention \ r \ Health care: Don't drink too much tea or coffee before going to bed at night, actively exercise and eat a balanced diet.
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treat cordially
primary objective
The main purpose of treating syncope patients should include preventing the recurrence of syncope and related injuries, reducing the death rate of syncope and improving the quality of life of patients. Most syncope is self-limited and a benign process. But when doctors deal with a fainting patient, the first thing they should think of is the situation that needs emergency rescue, such as cerebral hemorrhage, massive internal bleeding, myocardial infarction, arrhythmia and so on. The elderly with unexplained syncope should be suspected of complete heart block and tachycardia even if no abnormality is found in the examination. After finding a syncope patient, you should lower your head (droop when lying down, and put your head between your legs when sitting down) to ensure blood supply to your brain, unbutton your clothes, and turn your head to one side to prevent your tongue from blocking the airway. Spray a small amount of cold water on your face and apply a wet towel on your forehead to help you wake up. Keep warm and don't feed food. Don't stand up immediately after waking up. After the whole body is weak and improves, gradually stand up and walk. The risk of syncope in the elderly sometimes lies not in the primary disease, but in the head injury and limb fracture after syncope. Therefore, it is suggested that the bathroom and bathroom floor be paved with rubber blankets, and the bedroom be carpeted. Outdoor activities should be carried out on grass or land to avoid standing for too long.
Neural-mediated syncope
For nerve-mediated syncope, prevention is the most important, and education for patients is the most basic means. Patients should pay attention to behaviors that may induce syncope, such as hunger, fever and urination. , and avoid them as much as possible. They should also understand the premonitory symptoms of syncope and learn how to avoid losing consciousness: when there is a pre-syncope state, lie flat immediately to avoid activities that may cause harm. In addition, pay attention to the treatment of primary diseases that may induce syncope (such as diseases that cause cough). Vasodilators should be stopped because they will increase the incidence of syncope. Patients with insufficient blood volume should be supplemented with water. Vasovagal syncope is mostly benign. Special treatment may not be given to patients with single or rare syncope without risk factors. For heavier patients, some safer methods can be adopted, such as volume expansion, slight physical activity and tilt training (repeated tilt training for a long time until the patient's orthostatic reaction disappears). In recent years, some scholars at home and abroad have studied the treatment of vasovagal syncope with drugs and pacemakers, but its effectiveness and feasibility are still unclear. Some non-controlled or short-term controlled trials suggest that β -blockers and hydrocortisone have certain effects on vasovagal syncope, but there is still a lack of long-term controlled prospective research support. Pacemakers may prolong the aura of syncope, but it is difficult to prevent the attack, so they are not recommended. For carotid sinus allergy, patients should avoid wearing hard collar clothes, turn their heads slowly or gradually at the same time, and give corresponding treatment if there are local lesions. Usually you can take atropine or ephedrine to prevent seizures. Dual-chamber pacing therapy also has certain effect, especially for patients with bradycardia. For situational syncope, special behavior should be avoided as much as possible. For the inevitable behaviors such as defecation, methods such as maintaining blood volume, changing posture (from standing posture to sitting posture or lying posture) and slowing down the speed of posture change can be adopted. In addition, patients with defecation syncope use stool softener, patients with urination syncope drink less water, especially alcohol, and patients with swallowing syncope eat less cold drinks and large pieces of food, which is also beneficial to prevent syncope.
Patients with postural hypotension
The treatment of patients with postural hypotension should include fluid replacement when blood volume is insufficient, and stopping or reducing drugs that produce hypotension. Avoid standing and staying in bed for a long time, and abstinence from alcohol has a certain preventive effect. Other methods, such as increasing the intake of salt and liquid, using elastic socks and elastic abdominal belts, carrying folding chairs with you and exercising leg and abdominal muscles, are also helpful. If all the above methods fail, you can consider the drug treatment mentioned above.
Cardiogenic syncope
The treatment of cardiogenic syncope should first aim at myocardial ischemia, electrolyte disorder and other reasons. Bradycardia requires a pacemaker. Ephedrine, atropine and isoproterenol can be used to improve ventricular rate. Arrhythmia in some patients may be caused by drugs such as calcium blockers and membrane active drugs used to treat tachyarrhythmia, and should be stopped. If there is no improvement, pacemakers should be installed. Tachycardia mainly uses drugs or electrical cardioversion. The effect of drug therapy for supraventricular tachycardia is not clear, and catheter ablation can be used. Patients with ventricular tachycardia without heart failure or mild heart failure can use type III antiarrhythmic drugs (amiodarone is preferred), and patients with poor heart function can use implantable cardioverter defibrillator (ICD). Primary long QT syndrome is mainly treated by β -blockers and left stellate ganglion resection. If patients have organic heart disease, they should avoid strenuous exercise and give necessary drugs. If there are signs, operate as soon as possible. Coronary heart disease complicated with ventricular tachycardia often leads to sudden death, and ICD should be installed if necessary.
Syncope caused by cerebral syncope and mental illness
Cerebral syncope and syncope caused by mental illness can be treated with the help of experts. Hypoglycemia and anemia can be treated as usual
First aid for sudden fainting in the bath
Emergency treatment
1. When this happens, there is no need to panic. As long as you leave the bathroom and lie down and drink a cup of hot water immediately, you will gradually return to normal.
2. If it is heavy, relax and rest, take a supine position, and it is best to put books and clothes on your legs that you can get around. After a little better, you should open the window for ventilation, wipe your body from face to toes with a cold towel, then put on clothes and lean your head against the window, and you will recover.
Matters needing attention
1. To prevent discomfort during bathing, the bathing time should be shortened or interrupted. In addition, drink a cup of warm water before taking a bath.
2. Patients with heart diseases such as angina pectoris and myocardial infarction should avoid taking a bath for a long time.
3. Pay attention to exercise at ordinary times, improve physical fitness and stabilize the neuromodulation function of the body.
In order to prevent sudden fainting in the shower, a ventilator should be installed in the bathroom to keep the indoor air fresh.
Don't smoke while taking a bath, and leave the bathroom immediately after washing. [2]