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Questions for part D
Published in Henry J. Woodford, Essential Geriatrics, 2022
A 75-year-old man has had two episodes of syncope over the previous six months. On head-up tilt testing, his blood pressure dropped from 158/86 mmHg to a nadir of 101/57 mmHg. No significant pauses were detected in his pulse rate. He reported similar symptoms compared to his prior syncopal events. A diagnosis of vasovagal syncope is made. He has a past history of hypertension and peripheral vascular disease. His only current medication is clopidogrel and atorvastatin. What treatment would you offer him?Compression stockingsFludrocortisoneLifestyle advice onlyMidodrineSelective serotonin reuptake inhibitor
Syncope
Published in Stanley R. Resor, Henn Kutt, The Medical Treatment of Epilepsy, 2020
Douglas L. Wood, Bernard J. Gersh
Although most patients with vasovagal syncope will have premonitory symptoms of nausea, lightheadedness, and dimming of vision, some patients lose consciousness abruptly. Patients with cardiac arrhythmias generally lack a warning prodrome. Epilepsy often occurs abruptly, and when preceded by an aura, the symptoms are often sensory and the same pattern is generally repeated with each spell. Whereas the severity of symptoms in a patient with vasovagal syncope may be modified by lying supine or putting the head down, these measures usually do not alter the features of an epileptic seizure.
General Medical Emergencies
Published in Anthony FT Brown, Michael D Cadogan, Emergency Medicine, 2020
Anthony FT Brown, Michael D Cadogan
Ask about symptom patterns to suggest an underlying mechanism: Vasovagal syncope associated with an unpleasant trigger, previous episodes, prolonged standing, and prodromal nausea and light-headedness.Orthostatic syncope associated with standing up, certain drugs, autonomic disease and volume depletion.Cardiac syncope associated with exertion, positive family history, known structural heart disease, sudden onset +/– palpitations, absence of a prodrome, sitting or supine position.Following sudden breathlessness (PE), or headache (SAH).
Tests for the identification of reflex syncope mechanism
Published in Expert Review of Medical Devices, 2023
Michele Brignole, Giulia Rivasi, Artur Fedorowski, Marcus Ståhlberg, Antonella Groppelli, Andrea Ungar
The diagnosis of reflex (vasovagal) syncope requires reproduction of syncope along with the characteristic hemodynamic pattern of reflex hypotension/bradycardia [2,13]. At some moment after tilt-up, BP starts to decrease slowly and slightly for several minutes. At this stage HR increases slightly, indicating the activation of compensatory baroreflex mechanisms to orthostatic stress. HR then decreases, indicating the onset of cardioinhibition. Some degree of bradycardia is always present at the time of reflex syncope and indicates the activation of the vagal phase of the reflex. According to the magnitude of bradycardia, positive responses to TT are classified as VD (minimal heart rate decrease, i.e. less than 10%), mixed (heart rate decrease >10% but without asystolic pause >3 s) or CI (one or more asystolic pause >3 s) [50].
Immediate Interventions for Presyncope of Vasovagal or Orthostatic Origin: A Systematic Review
Published in Prehospital Emergency Care, 2020
Jan L. Jensen, Shinichiro Ohshimo, Pascal Cassan, Daniel Meyran, Jennifer Greene, Kee Chong Ng, Eunice Singletary, David Zideman
Two important studies utilizing PCM did not meet our inclusion criteria but support our findings. The Physical Counter Pressure Maneuvers Trial was a large, multicenter RCT evaluating the use of PCM in daily life in 223 participants, aged 16–70 years, with recurrent vasovagal syncope over a 6–18 month time span (13). This study measured syncope burden in terms of episodes per year and found a significant reduction in median (interquartile range) yearly episodes per patient with the use of PCM (0.0 [0.0–0.7]) compared with the conventional treatment group (0.6 [0.0–1.3], p = 0.004), as well as a relative risk reduction (95% CI) for syncope recurrence of 0.36 (0.11–0.53, p = 0.005) and with no adverse events. The authors concluded that PCMs are a low-risk, effective, and low-cost treatment modality in patients with VV and should be used as a first-line treatment in this group. A prospective observational study of 85 enrollees with a mean age of 62 years compared syncope recurrence in participants with a diagnosis of hypotensive neurally-mediated syncope who were trained in the use of PCM and lifestyle changes (4). The syncope recurrence rate at 21 months with the use of PCM was 42% (27–61) and was without PCM 64% (48–80; p = 0.27), with a relative risk reduction of 34%. These studies support the use of PCM for patients with vasovagal syncope and suggest it may be more effective in patients of a younger age and with a sufficient prodromal (presyncope) period.
The Utility of Fundus Fluorescein Angiography in Neuro-Ophthalmology
Published in Neuro-Ophthalmology, 2019
Revelle Littlewood, Susan P Mollan, Irene M Pepper, Simon J Hickman
Between 5% and 20% of patients who undergo injections of fluorescein will experience one or more side-effects. Some appear quite quickly following injection and usually disappear without any major consequence. More serious reactions occur rarely (less than 1% of injections). When consenting someone for this test the following should be mentioned: transient skin and urine discolouration, which may last up to 36 h in a normal patient (longer in those who have renal impairment, see contraindications below); extravasation of dye at injection site with local irritation/thrombophlebitis; nausea and vomiting, which is typically short-lived but may interfere with the crucial early images and pruritis. Some may experience vasovagal syncope (1 in 340) or anaphylaxis (1 in 1,900). Fatal anaphylaxis is rarely reported with a frequency of approximately 1 in 220,000 injections. Hence, it is recommended that resuscitation equipment is available in the same room where the injection is given.1,2