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Vanderbilt Core Clinical Curriculum

Syncope

Syncope and loss of consciousness is a common presentation of severe illness. Coma is a state of unconsciousness from which the patient cannot be aroused, even by powerful stimulation. Loss of consciousness has many etiologies, many of which can be life threatening.

Required Skills/Procedures:

1. Perform situation-appropriate (problem-focused or complete) history and physical examinations
2. Interpret clinical information to formulate a prioritized differential diagnosis
3. Guide the creation of a patient-specific management plan

Appropriate Setting: Inpatient and Outpatient

Expected level of Responsibility: Direct supervision with real patients

Learning Topics during encounters with a patient with SYNCOPE can include:

Medical Knowledge Learning Topics related to SYNCOPE

1. Initial assessment and stabilization of the patient

2. Principal etiologies of coma:

  • widespread damage in both hemispheres from ischemia, trauma, or other less common brain diseases
  • suppression of cerebral function by extrinsic drugs, toxins, or hypoxia, or by internal metabolic derangements such as hypoglycemia, azotemia, hepatic failure, or hypocalcemia
  • brainstem lesions that cause proximate damage to the RAS

3. Symptoms and signs of coma

4. Diagnostic criteria for common etiologies of coma, based on a history, physical exam and laboratory testing

5. Indications and the limitations of clinical examinations to determine existence of coma and differentiate among common etiologies of coma, including:

  • appearance of patient
  • interrogation
  • history from third parties (family, friends, or care givers)
  • physical examination, including vital signs
  • brief neurological exam
  • central nervous system exam

6. Indications for drug therapy and therapeutic procedures in patients with common causes of coma, and the physiological basis and/or scientific evidence supporting each

7. Indications for empiric therapy in patients who are comatose

8. Critical pathway for patients who are comatose

9. Principal causes of syncope

10. Differentiate syncope from seizure

11. Orthostatic BP and the significance of pulse changes

12. Heart sounds of aortic stenosis and hypertrophic obstructive cardiomyopathy

Diagnostic Evaluation Learning Topics related to SYNCOPE

Syncope

1. Physical exam that focuses on determining the causes of syncope to include carotid sinus hypersensitivity, volume depletion, abnormal heart tones or heart tone changes with position, and autonomic dysfunction

2. Differential diagnosis that differentiates between neurally mediated syncope, orthostatic hypotension, cardiovascular causes of syncope, neurological causes of syncope, and other causes

Coma

1. Initial assessment and stabilization of the patient who appears to be comatose:

  • airway maintenance with cervical spine control
  • breathing and ventilation
  • circulation with hemorrhage control
  • neurological status, disability
  • environmental control

2. Age-appropriate medical history, that differentiates among etiologies of disease

3. Physical exam and CNS assessment to establish the diagnosis and severity of disease using the Glascow scale

For Syncope and Coma

1. Differential diagnosis, recognizing specific history and physical exam findings.

2. Utility and interpretation of diagnostic and laboratory tests necessary to determine the cause of a patient’s coma or syncopal episode both prior to and after initiating treatment based on the differential diagnosis. Consideration of test cost and performance characteristics as well as patient preferences

3. Explanation of the results of the evaluation to the patient, taking into consideration the patient’s condition and knowledge about his/her condition.

Management Plan Learning Topics related to SYNCOPE

1. Management of the cause of the patient’s syncope

2. Stabilization the comatose patient based on initial assessment and revise based on subsequent findings:

  • airway maintenance with cervical spine control
  • breathing and ventilation
  • circulation with hemorrhage control
  • empiric treatment of reversible causes
  • thiamine 100mg (adults)
  • dextrose 50 mls 50% (adults)
  • naloxone 0.4 mg (adults)
  • stop seizures
  • treat metabolic disturbances
  • lower intra-cranial pressure
  • treat infection

3. General management elements of coma as appropriate:

  • ABCDE
  • take blood test while putting in lines
  • nursing attention to pressure areas and eyes
  • bronchial toilet
  • nutrition needs – NG tube
  • bladder care – catheter
  • monitoring – vital signs and neurology

4. Communication of the diagnosis, treatment plan, and prognosis of the disease to patients and their families in a caring and compassionate manner. Understanding of the emotional impact of the diagnosis and its potential effect on lifestyle (work performance, sexual functioning, etc.).

Potential Differential Diagnosis Topics Include:

Syncope

Neurally mediated syncope

  • vasovagal
  • carotid sinus hypersensitivity
  • situational

Orthostatic hypotension

  • volume depletion
  • drug induced
  • autonomic instability

Cardiovascular causes of syncope

  • arrhythmia,
  • obstructive shock (PE, Pulm HT, RV AMI, Pericardial Tamponade, AS, IHSS)

Neurological causes of syncope

  • subarachnoid hemorrhage
  • intracranial hemorrhage
  • intracranial mass

Other causes

  • hypoglycemia

Coma

Intracranial

  • vascular
  • infection
  • tumor
  • post epileptic
  • head injury
  • psychiatric

Extracranial

  • cardiovascular
  • infection
  • metabolic
  • drugs