Transcript: Workup For Syncope In Primary Care

Liz Rohr:
Hey, there. It's Liz Rohr from Real World NP and you are watching the Real World NP YouTube channel. We make weekly episodes to help save you time, frustration and help you take the best care of your patients.

Liz Rohr:
Hello. This episode, we are going to be talking about syncope. So the way I want to approach this video is thinking about being a nurse practitioner in primary care. Somebody comes in and their chief complaint is syncope. I've talked about this in a couple of videos, but the longer you are in practice as a nurse practitioner and the larger the knowledge base you develop, when you go into a visit, you start with the differentials in the front of your mind and you work your way backwards. So I want to work through this episode in that way, acknowledging that if you are a new grad or student listening to this, this is not going to be the way that it is for you in primary care.

Liz Rohr:
The hack of getting around that is like I've mentioned in other symptom-based videos and episodes, which is using the acronyms of OLD CART, onset, location, duration, et cetera, in your history taking and then doing a full ROS and physical exam to kind of work your way backwards into the differentials. But anyway, we'll start with the general categories of differentials for syncope and then we'll get into the history questions, the physical exam, and red flags to watch out for, as well as some of the testing we want to watch out for. And I really want to tie them back to those general categories of differentials.

Liz Rohr:
So let's first talk, what is the definition of syncope? And this is important, not for semantics, but actually in practice because patients who come in saying that they had a syncopal episode or they fainted, it could be true syncope or it could be pseudo syncope. It could be something else. So it's a transient loss of consciousness that is caused by a period of inadequate cerebral blood flow and nutrients. It's quick onset, it's brief, and it's self-limited. That's the definition of a transient loss of consciousness, aka, syncope.

Liz Rohr:
Next, I want to talk about those four main categories of causes. I'm not going to talk about every single differential that exists, because that is very long. This is one of those doorway episodes. If you haven't listened to many of my episodes before, a lot of the hacks that I use to keep things straight in my mind when there's so much knowledge to know, is knowing what is the first place to start. What is that first level of knowledge that I must have for this chief complaint or this topic that will lead me to my next doorway of where to go to pursue that information further? Especially in those really huge, broad differential chief complaints, and this is potentially one of them, what are those four main places to start in terms of categories? And then once you get there, what's the doorway that you're going to open that's leading you towards one direction? And then you can consult your further resources to build out your knowledge and your investigation further. So this is the doorway episode.

Liz Rohr:
Four main categories of syncope. The first one is called reflex mediated. So if you're a student or a newer grad, you might be like, what are we talking about here? So it's fascinating. Actually, again, this is a doorway so definitely something to investigate if you're not feeling comfortable with all the differentials inside of reflex mediated syncope, but those are traditionally things that are like triggered by something else that causes a syncopal event. Commonly this is vasovagal responses. Some people have that vasovagal response, they have a syncopal episode. Micturition, voiding and defecation, those can also trigger a syncopal event. Interesting. As can swallowing and coughing and sneezing. Fun fact. Definitely read about reflex media. Those are not the only options, but there is like something that it triggers the event. And so definitely deepen your knowledge based in that if you're not familiar with those differentials.

Liz Rohr:
The next one is orthostatic hypotension. That's the general parent category and the children are like the little differentials. What are the general categories inside orthostatic hypotension? Medication related, primarily, predominantly, most common ones are caused by diuretics, vasodilators, specifically calcium channel blockers, nitrates, alpha-blockers. Those are really common, not the only options, but very common ones. Volume depletion states, hemorrhage, GI illness, et cetera, and various autonomic reasons.

Liz Rohr:
This is a little bit of a zebra-ish place to go. But just keeping in mind, again, this is like the doorway to pursue down. So Parkinson's, secondary to other illnesses, amyloidosis, diabetes, stuff like that. Go down that doorway, if you want to go down that doorway, but the moral of the story is second major cause is orthostatic hypotension from whatever underlying cause there is.

Liz Rohr:
So just think about reflex-mediated, orthostatic hypertension, and then the next one is cardiopulmonary disease. This is a broad category as well. So we're thinking things like arrhythmias, cardiac arrhythmias, structural heart disease, cardiomyopathy, severe aortic stenosis, pulmonary embolism, pulmonary hypertension. Again, this is a doorway. So go into that pathway if you're thinking more on that line, but as long as you're keeping those first three things in your mind, first three categories, that will help you guide your visit to ask the appropriate history questions, physical exam, or the tests, et cetera.

Liz Rohr:
So next I want to talk about pseudo syncope. So the things we really want to be careful of is getting our adequate history with these patients because we have to figure out what direction to go. The other things you want to be mindful of that are not actually syncope are things like seizures, sleep disturbances of a variety of kind, that's like the parent category. Accidental falls, metabolic and electrolyte disturbances can contribute to cognitive changes, but not necessarily true syncope. Some psychiatric conditions, whether it's a pseudo seizure or something else that's going on. So just being really mindful of, is this actually true syncope in those three first categories or is it something else?

Liz Rohr:
Next let's talk about the history questions. So as I mentioned at the beginning, there's OLD CART, onset, location, duration, et cetera, but there are specific questions to ask for syncope so I want to go over some of those. You want to talk about how many episodes this person has had, how long do they last, how often it's happening. Is this the first time, multiple times? Were there any symptoms prior to the episode? Because we're tying it back to reflex mediated causes, voiding, defecating. Were they diaphoretic? Were they nauseous? Did they have palpitations? Were they hot, cold? Did they have chest pain? Shortness of breath? Tying it back to those categories. Position of their body before or after the episode, again, tying back to orthostasis? Were they going from sitting to standing and then they fainted, lost consciousness, et cetera? And if it's happened a number of times, is there something that's consistently seeming to trigger it? Is it all kind of tied together?

Liz Rohr:
And a really important question is, were they by themselves or were they with somebody else? Because if there was a witness, we really want to ask that person too. What did you see? Did they have any physical movements? Are we trying to rule out if this is an actually like a seizure instead of a syncopal event? Was there any change in their breathing? What did they look like? Were they cyanotic appearing? Using the appropriate language with a person who's with them. Any other preexisting conditions that we know about already? Medications that they're taking?

Liz Rohr:
And then family history is always a good one to throw in. I feel like I missed that aspect of the evaluation when I was a newer grad. I would have family history as part of my assessment, but I just didn't make that connection of how important answering that question is. And you can give them options. Because again, we're looking for cardiopulmonary disease here. Did they have any arrhythmia, structural heart disease, heart attack stroke, et cetera?

Liz Rohr:
One note here, important note I want to make, is that actually reduced blood flow to the brain from cerebral artery atherosclerosis is actually quite uncommon. So it is a possibility, but it's actually not the most common thing to think about.

Liz Rohr:
Let's talk about some red flags to watch out for. So you've probably put this together already and you have those categories in your mind, but let's just put it in a little list here. Exertional onset. Why do we care about that? Because we're worried about something cardiac going on, cardiopulmonary. Chest pain, dyspnea, palpitations, focal, neurologic deficits. Of course we want to see what's going on with that. Things like diplopia, ataxia, dysarthria, speech, visual changes, weakness. Severe headache would be really concerning too because we could potentially be tying into some sort of vascular thing going on that contributed to the loss of consciousness. Those are the main red flags to watch out for.

Liz Rohr:
In terms of the evaluation, you want to do your full physical exam specifically focusing in on HEENT, cardiovascular, their general appearance, of course, pulmonary, because we're trying to get into those categories. And then it's more additional exam testing things we want to think about. We want to do blood pressures in both arms, even if you're not really sure what the structural cardiac abnormality might be that's one piece of evidence to help support yes or no. Is there something going on there cardiovascular wise? So testing it in both arms, seeing if there's a discrepancy between blood pressures.

Liz Rohr:
Absolutely orthostatic vital signs. I know they're not the most fun thing to do, but hopefully you can get your support staff to help you with them if you cannot yourself. That is absolutely must, vital, one of the categories. EKG is wise to do because we want to look for arrhythmia. You can find some signs of structural abnormalities on your EKG, definitely seeking out support if you need help with interpretation.

Liz Rohr:
And consider labs based on their history. So CMP, complete metabolic panel. We want to think about, are there electrolyte disturbances? Does that make sense based on their history? A CBC, do they have underlying anemia or something else like that? A1C perhaps, if we're thinking maybe they have some underlying diabetes which could be contributing in a secondary way to that reflex mediated one. It's a little bit complicated, but one thing to watch out for.

Liz Rohr:
And then you just really kind of take it from there. In terms of the management, it really depends on the history, your exam, and where you're kind of going with each of those doorways. Just to recap that, reflex mediated and digging into that if you're not feeling super comfortable with that, orthostatic hypotension from whatever cause, and cardiopulmonary disease. So depending on your assessment and your labs, you get to make that decision of, who do I need support from next?

Liz Rohr:
I don't even think I mentioned neurologic exam in my physical exam. I think I was just like intuiting that, but that is absolutely part of your physical exam. So I don't want to leave that out. You want to decide, do you need cardiology to help you? Do you need neurology to help you? Do you need your supervising, collaborating provider to help you? Things like that.

Liz Rohr:
That's it. Hopefully that's a helpful summation of the approach to diagnosing syncope in primary care. If you haven't grabbed the ultimate resource guide for the new NP head over to realworldnp.com/guide. You'll get all of these episodes sent straight to inbox every week with notes from me, patient stories, and bonuses I truly don't share anywhere else. Thank you so very much for watching. Hang in there and I'll see you soon.