Syncope: Emergency, Management, Treatment
Discover causes, symptoms, and treatments for syncope (fainting) on our comprehensive medical guide. Learn how to manage sudden loss of consciousness effectively. Get expert insights now
Table of Contents
Micturition syncope
- Micturition syncope, also known as post-micturition syncope, is a phenomenon where individuals faint shortly after or during urination.
- The underlying cause of micturition syncope is not entirely understood but may involve a vasovagal response, postural hypotension, or a combination of both factors.
- This condition typically presents with symptoms such as pallor, lightheadedness, nausea, sweating, and weakness before the loss of consciousness occurs.
- In some cases, activities like defecation, coughing, or severe vomiting can also lead to fainting in a similar manner.
Causes of micturition syncope
- One common trigger for micturition syncope is the stimulation of the vagus nerve when straining to increase urine flow.
- This response can be more pronounced in elderly men with enlarged prostates.
- The vagus nerve stimulation results in bradycardia (slowing of the heart rate) and a decrease in blood pressure.
- Insufficient blood supply to the heart due to these changes can impair its pumping function.
- Additionally, there have been rare cases associated with a tumour called paraprostatic pheochromocytoma located within the urinary bladder.
Treatment of micturition syncope
- There is no specific treatment for micturition syncope; however, general advice for individuals experiencing this condition includes:
- Sitting while urinating
- Sitting on the edge of the bed for a brief period before standing up and going to the toilet
- Avoiding urination when feeling sleepy
- Urinating before going to sleep
Stopping urination, crossing and flexing legs upon feeling faintness
What is Defecation syncope?
- Defecation syncope is a relatively rare disorder that typically occurs in middle-aged or older individuals and affects women somewhat more often than men.
- Pathy first described it in 1978, and Kapoor and colleagues investigated further.
- Defecation syncope is defined as syncope occurring during or immediately after defecation.
- Unlike micturition syncope, there is no strong diurnal variation in defecation syncope.
- About half of the patients with defecation syncope experience multiple episodes, and most patients are recumbent before getting up to have a bowel movement.
- Gastrointestinal symptoms before syncope can include a strong urge to defecate, abdominal cramps and bloating, nausea and vomiting, diarrhoea, and constipation.
- Patients experiencing defecation syncope may also have associated brief jerking or rhythmic movements (convulsive syncope), but there is no associated incontinence, tongue biting, or postictal state.
- Recovery usually occurs within seconds, without vasomotor or other sequelae.
- The long-term prognosis of defecation syncope depends largely on the prognosis of the underlying condition, but it is noted that more than one third of patients with defecation syncope die within 2 years due to complications of their underlying diseases.
What is Swallowing syncope?
- Swallowing syncope is a rare form of syncope that occurs when a patient faints or passes out after swallowing food.
- The reflexes initiated during swallowing can lead to syncope, where specific triggers align to cause this phenomenon.
- Factors such as dehydration, fatigue, improper chewing leading to food blockage in the throat, and subsequent coughing can trigger a reflex, causing the brain to signal the heart to slow down and blood vessels to dilate, resulting in low blood pressure and potential fainting
Causes of Swallowing Syncop
- Swallowing syncope is caused by upper gastrointestinal-cardiac vagovagal reflexes that are activated by swallowing and rapid gastric distension.
- This condition is considered one of several neurally mediated syncopes that can occur after various activities like micturition, defecation, coughing, or laughing.
- Swallow syncope may occur within seconds of swallowing, leading to presyncope or full loss of consciousness.
- Liquids, particularly cold carbonated beverages, can trigger it, but solid foods have also been reported to do so in some cases.
Treatment for Swallowing Syncope
- The treatment for swallow syncope focuses on proper swallowing techniques such as taking small bites, chewing thoroughly, and being mindful of when to swallow.
- Patients may need to avoid specific types of foods that trigger their symptoms.
- Staying well-hydrated and maintaining a comfortable environment while eating can also help manage swallow syncope episodes.
- In severe cases where syncope significantly impacts quality of life and is associated with heart abnormalities like atrioventricular block or sinus arrest during swallowing, a pacemaker may be considered
What is orthostatic syncope?
- Orthostatic syncope, also known as postural syncope or orthostatic hypotension, is a condition characterized by a sudden drop in blood pressure that occurs when standing up after sitting or lying down.
- This drop in blood pressure can lead to dizziness, lightheadedness, and fainting.
- Orthostatic syncope is a type of syncope, which is the medical term for fainting or passing out.
Symptoms of Orthostatic Syncope
- The symptoms of orthostatic syncope include lightheadedness or dizziness upon standing, blurry vision, weakness, fainting (syncope), and confusion.
- These symptoms typically last for a few minutes after changing positions.
- The symptoms become worse when they arise in the morning, after meals or after exercise
Causes of Orthostatic Syncope
- Orthostatic syncope occurs when there is an interruption in the body’s normal response to low blood pressure when changing positions.
- Various conditions can lead to orthostatic syncope, including dehydration, heart problems such as bradycardia or heart failure, endocrine issues like thyroid conditions or low blood sugar, nervous system disorders like Parkinson’s disease, and postprandial hypotension (low blood pressure after eating).
Risk Factors for Orthostatic Syncope
- Factors that increase the risk of developing orthostatic syncope include age (more common in individuals aged 65 and older), certain medications that affect blood pressure regulation, dehydration, heart conditions, and nervous system disorders. [7]
What is drug induced syncope?
- Drug-induced syncope is a term used to describe episodes of fainting or passing out caused by certain medications.
- These medications can lead to syncope through various mechanisms, such as causing bradycardia (slow heart rate), tachyarrhythmias (fast irregular heart rhythms), prolonging the QT interval (a measure of heart rhythm), or inducing orthostatic hypotension (a drop in blood pressure upon standing).
- Some common classes of medications known to potentially cause drug-induced syncope include beta blockers, sodium channel blockers, drugs that prolong the QT interval, antihypertensives, peripheral vasodilators, diuretics, phenothiazines, antidepressants, alcohol, and illicit drugs.
- In older adults and seniors, the risk of drug-induced syncope may be higher due to age-related changes in physiology and increased susceptibility to medication side effects.
- Additionally, factors like dehydration, volume depletion, and exposure to hot weather can exacerbate the orthostatic effects of certain medications in this population.
- It is crucial for healthcare providers to be aware of the potential for drug-induced syncope when prescribing medications to older adults and to monitor for signs and symptoms that may indicate a risk of syncope.
- Adjustments in medication regimens or dosages may be necessary to minimize the likelihood of syncope episodes in susceptible individuals.
What is pacemaker related syncope?
- Pacemaker-related syncope refers to fainting or loss of consciousness that is directly linked to issues with a pacemaker.
- A pacemaker is a small device implanted in the chest or abdomen to help control abnormal heart rhythms.
- It can occur when there are problems with the pacemaker’s function, such as pacing issues, lead dislodgement, battery depletion, or programming errors.
- When a pacemaker fails to deliver the necessary electrical impulses to regulate the heart rate effectively, it can result in a temporary pause in the heartbeat or an irregular rhythm.
- This disruption in the heart’s normal functioning can lead to decreased blood flow to the brain, causing syncope or fainting episodes.
- Patients who experience pacemaker-related syncope may exhibit symptoms such as dizziness, lightheadedness, palpitations, shortness of breath, and, in severe cases, loss of consciousness.
- It is essential for individuals with pacemakers who experience these symptoms to seek immediate medical attention to determine the underlying cause and prevent further complications.
- Diagnosing pacemaker-related syncope involves a thorough evaluation by healthcare professionals, including checking the pacemaker settings, conducting electrocardiograms (ECGs), and performing other tests like Holter monitoring or electrophysiology studies.
- Treatment options may vary depending on the specific cause identified but can include adjusting pacemaker settings, replacing leads or batteries if necessary, or reprogramming the device.
What is nitrate induced syncope?
- Nitrate-induced syncope is a condition where a sudden drop in blood pressure occurs after the ingestion of nitrates, leading to fainting or loss of consciousness.
- This can be particularly dangerous, especially for elderly patients or individuals with underlying heart conditions.
- It is essential for healthcare providers to be aware of the potential side effects of nitrates, such as hypotension leading to unconsciousness, especially in vulnerable populations like the elderly.
- Syncope caused by nitrates can be a serious problem that requires immediate medical attention and management.
- Patients who experience nitrate-induced syncope should be closely monitored and may need adjustments to their medication regimen to prevent future episodes.
What are the phases of syncope?
- The clinical manifestations of syncope can be grouped into 3 different phases:
- Presyncope
- Syncope
- Post syncope (recovery period)
presyncope phase
- It is also known as prodromal phase.
- Presyncope is the phase where an individual experiences symptoms that indicate they are about to faint but do not actually lose consciousness.
Signs and symptoms of presyncope phase
- lightheadedness
- weakness
- dizziness
- confusion
- tunnel vision
- blurry vision
- slurred speech
- trouble hearing
- sweating
- nausea or vomiting
- headache
- heart palpitations.
These symptoms can last from a few seconds to several minutes before subsiding.
Etiopathogenesis (development of a disease)
- When a person experiences stress, which can be caused either emotionally by fear or sensorially by pain, catecholamines are released into the bloodstream.
- The release of catecholamines, like epinephrine and norepinephrine, initiates the fight or flight response.
- Due to this response, there is a decrease in peripheral vascular resistance and an increase in blood flow to the skeletal muscles.
- After this, there can be two possibilities: either the muscular activity can occur or the muscular activity does not occur.
- If the muscular activity occurs, the blood is pumped back from the muscles to the heart, and there is no peripheral pooling of the blood. So the blood pressure remains at the baseline level, and there is no development of signs or symptoms of syncope.
- If muscular activity does not occur, then there is peripheral pooling of blood in the muscles, which leads to decreased blood return to the heart. This further leads to decreased circulating blood volume and a decrease in cerebral blood flow, which leads to syncope.
Causes of presyncope phase
The causes of presyncope can vary and may include –
- a temporary drop in blood pressure, dehydration
- prolonged standing
- intense nausea or pain
- hypoglycemia (low blood sugar)
- neurally mediated hypotension (drop in blood pressure upon standing)
- vagal presyncope triggered by specific stimuli like
- emotional reactions or large meals
- side effects of certain medications that lower blood pressure
- in rare cases, cardiac arrhythmias.
- When experiencing presyncope symptoms, it is crucial to seek medical attention to rule out any serious underlying health conditions that may require treatment.
- Diagnostic tests may be conducted to determine the exact cause of presyncope.
- Treatment for presyncope depends on the underlying cause.
- If no specific medical condition is identified, management may involve avoiding triggers such as sudden position changes or staying hydrated.
syncope phase
- It is also known as the loss-of-consciousness phase.
- During this phase:
- The individual becomes unresponsive and may fall if standing.
- Muscle tone is lost (postural tone), leading to collapse.
- Breathing may become shallow but usually continues without interruption.
- The blood pressure is decreased, and the pupils of the patient dilate, leading to a deathlike experience.
- It usually lasts from a few seconds to a few minutes.
- The pulse of the patient becomes very weak.
- The patient is placed in a supine position.
- Understanding the loss of consciousness phase in syncope is crucial for diagnosis and management.
- Identifying triggers and symptoms can help differentiate between types of syncope (e.g., vasovagal vs. cardiac).
- Patients experiencing recurrent episodes should undergo a thorough evaluation to rule out serious underlying conditions such as arrhythmias or structural heart disease.
- The loss of consciousness phase in syncope is caused by complex interactions between cardiovascular dynamics and autonomic nervous system responses, which lead to transient cerebral hypoperfusion. [8]
post syncope phase
- It is also known as the recovery period.
- The post-syncope phase is characterized by rapid recovery of consciousness with potential lingering physical and emotional effects that require monitoring and possibly further evaluation.
- The patient may experience a short period of disorientation or confusion.
- The post-syncope phase refers to the period immediately following a syncopal episode, characterized by the recovery of consciousness and the return of normal neurological function.
- This phase can vary significantly among individuals, but it generally includes several common features:
- Immediate Recovery: After syncope, most individuals regain consciousness quickly, often within seconds to a few minutes. They may feel disoriented or confused initially but typically return to their baseline cognitive state shortly thereafter.
- Physical Symptoms: Patients may experience various physical symptoms during the post-syncope phase, including fatigue, weakness, lightheadedness, nausea, or palpitations. These symptoms are often due to transient cerebral hypoperfusion that occurred during the syncopal event.
- Emotional Response: It is not uncommon for individuals to feel anxious or embarrassed after regaining consciousness, especially if they were in a public setting when the episode occurred. Some may also experience a sense of confusion about what happened.
- Assessment and Monitoring: After an episode of syncope, it is crucial for healthcare providers to assess the patient’s vital signs and perform a brief neurological examination to rule out any underlying conditions that could have caused the syncope. This assessment helps determine whether further evaluation or intervention is necessary.
- Recovery Time: The duration of recovery can vary; while many people feel back to normal within minutes, others might take longer to fully recover their strength and composure. Factors influencing recovery time include the individual’s overall health status and any underlying medical conditions.
- Follow-Up Care: Depending on the cause of syncope and individual risk factors, follow-up care may be recommended. This could involve lifestyle modifications (e.g., increasing fluid intake), medication adjustments, or further diagnostic testing if there are concerns about recurrent episodes.
- Education and Prevention: Educating patients about recognizing prodromal symptoms (such as dizziness or lightheadedness) can help them take preventive measures in future situations where they might be at risk for syncope.
