Dr. Francis SANWO

Syncope, commonly known as fainting, or passing out, is a loss of consciousness and muscle strength characterized by a fast onset, short duration, and spontaneous recovery. It is caused by a decrease in blood flow to the brain, typically from low blood pressure. There are sometimes symptoms before the loss of consciousness such as lightheadedness, sweating, pale skin, blurred vision, nausea, vomiting, or feeling warm. Syncope may also be associated with a short episode of muscle twitching. Psychiatric causes can also be determined when a patient experiences fear, anxiety, or panic; particularly before a stressful event usually medical in nature. When consciousness and muscle strength are not completely lost, it is called presyncope. It is recommended that presyncope be treated the same as syncope.

A medical history, physical examination, and electrocardiogram (ECG) are the most effective ways to determine the underlying cause. The ECG is useful to detect an abnormal heart rhythm, poor blood flow to the heart muscle and other electrical issues. Syncope affects about three to six out of every thousand people each year. It is more common in older people. It is the reason for one to three percent of visits to emergency departments and admissions to hospital. Of those presenting with syncope to an emergency department, about 4% died in the next 30 days. The risk of a poor outcome, however, depends very much on the underlying cause.

Causes.

Causes range from non-serious to potentially fatal. There are three broad categories of causes: heart or blood vessel related; reflex, also known as neurally mediated; and orthostatic hypotension. Issues with the heart and blood vessels are the cause in about 10% and typically the most serious while neurally mediated is the most common. There also seems to be a genetic component to syncope.

Neurally mediated syncope

Reflex syncope or neurally mediated syncope occurs when blood vessels expand and heart rate decreases inappropriately leading to poor blood flow to the brain. This may occur from either a triggering event such as exposure to blood, pain, strong feelings, or a specific activity such as urination, vomiting, or coughing.

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Vasovagal syncope…

Vasovagal syncope occurs when you faint because your body overreacts to certain triggers, such as the sight of blood or extreme emotional distress. It may also be called neurocardiogenic syncope.

The vasovagal syncope trigger causes your heart rate and blood pressure to drop suddenly. That leads to reduced blood flow to your brain, causing you to briefly lose consciousness.

Vasovagal syncope is usually harmless and requires no treatment. But it's possible that you may injure yourself during a vasovagal syncope episode. Your doctor may recommend tests to rule out more-serious causes of fainting, such as heart disorders.

Symptoms

Before you faint due to vasovagal syncope, you may experience some of the following: Pale skin, lightheadedness, tunnel vision — your field of vision narrows so that you see only what's in front of you, nausea, feeling warm, a cold, clammy sweat and blurred vision.

During a vasovagal syncope episode, bystanders may notice:  jerky, abnormal movements, a slow, weak pulse and dilated pupils.

Recovery after a vasovagal episode generally begins in less than a minute. However, if you stand up too soon after fainting — within about 15 to 30 minutes — you're at risk of fainting again. Fainting can be a sign of a more serious condition, such as a heart or brain disorder. You may want to consult your doctor after a fainting spell, especially if you've never had one before.

Vasovagal syncope occurs when the part of your nervous system that regulates heart rate and blood pressure malfunctions in response to a trigger, such as the sight of blood.

Your heart rate slows, and the blood vessels in your legs widen (dilate). This allows blood to pool in your legs, which lowers your blood pressure. Combined, the drop in blood pressure and slowed heart rate quickly reduce blood flow to your brain, and you faint.

Sometimes there is no classical vasovagal syncope trigger, but common triggers include: standing for long periods of time, heat exposure, seeing blood, having blood drawn, fear of bodily injury and straining, such as to have a bowel movement.

Vasovagal syncope can be considered in two forms:

Isolated episodes of loss of consciousness, unheralded by any warning symptoms for more than a few moments. These tend to occur in the adolescent age group and may be associated with fasting, exercise, abdominal straining, or circumstances promoting vaso-dilation (e.g., heat, alcohol). 

Recurrent syncope with complex associated symptoms. This is neurally mediated syncope (NMS). It is associated with any of the following: preceding or succeeding sleepiness, preceding visual disturbance ("spots before the eyes"), sweating, lightheadedness.

Syncope has been linked with psychological triggers. This includes fainting in response to the sight or thought of blood, needles, pain, and other emotionally stressful situations. "Blood-injury phobia", as this is called, is experienced by about 15% of people.

Syncope may be caused by specific behaviors including coughing, urination, defecation, vomiting, swallowing (deglutition), and following exercise.

Prevention. You may not always be able to avoid a vasovagal syncope episode. If you feel like you might faint, lie down and lift your legs. This allows gravity to keep blood flowing to your brain. If you can't lie down, sit down and put your head between your knees until you feel better.

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Diagnosis

Diagnosing vasovagal syncope often begins with a physical examination which include heart rate, blood pressure.

Your doctor may also recommend several tests to rule out other possible causes of your fainting — particularly heart-related problems. These tests may include:

Electrocardiogram. This test records the electrical signals your heart produces. It can detect irregular heart rhythms and other cardiac problems. You may need to wear a portable monitor for at least a day or as long as a month.

Echocardiogram. This test uses ultrasound imaging to view the heart and look for conditions, such as valve problems, that can cause fainting.

Exercise stress test. This test studies heart rhythms during exercise. It's usually conducted while you walk or jog on a treadmill. Blood tests. Your doctor may look for conditions, such as anemia, that can cause or contribute to fainting spells.

Treatment

In most cases of vasovagal syncope, treatment is unnecessary. Your doctor may help you identify your fainting triggers and discuss ways you might avoid them.

However, if you experience vasovagal syncope often enough to interfere with your quality of life, your doctor may suggest trying one or more of the following remedies:

Medications and Therapies. Your doctor may recommend ways to decrease the pooling of blood in your legs. These may include foot exercises, wearing compression stockings or tensing your leg muscles when standing. Avoid prolonged standing — especially in hot, crowded places — and drink plenty of fluids.

 Avoiding what brings on the syncope and possibly greater salt intake is often all that is needed.

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Cardiac. Heart-related causes may include an abnormal heart rhythm, problems with the heart valves or heart muscle, or blockages of blood vessels from a pulmonary embolism or aortic dissection, among others.

The most common cause of cardiac syncope is cardiac arrhythmia (abnormal heart rhythm) wherein the heart beats too slowly, too rapidly, or too irregularly to pump enough blood to the brain. Some arrhythmias can be life-threatening.

Two major groups of arrhythmias are bradycardia and tachycardia.

Blockages in major vessels or within the heart can also impede blood flow to the brain. Aortic stenosis and mitral stenosis are the most common examples. Major valves of the heart become stiffened and reduce the efficiency of the hearts pumping action. This may not cause symptoms at rest but with exertion, the heart is unable to keep up with increased demands leading to syncope.

 

To be continue next week

Blood pressure.

Orthostatic (postural) hypotensive syncope is caused primarily by an excessive drop in blood pressure when standing up from a previous position of lying or sitting down. When the head is elevated above the feet the pull of gravity causes blood pressure in the head to drop. If the blood pressure is not adequately maintained during standing, faints may develop. However, the resulting "transient orthostatic hypotension" does not necessarily signal any serious underlying disease. It is as common or perhaps even more common than vasovagal syncope.

This may be due to medications, dehydration, significant bleeding or infection. The most susceptible individuals are elderly frail individuals, or persons who are dehydrated from hot environments or inadequate fluid intake. For example, medical students would be at risk for orthostatic hypotensive syncope while observing long surgeries in the operating room.   

Seizures and syncope can be difficult to differentiate. Both often present as sudden loss of consciousness and convulsive movements may be present or absent in either. Movements in syncope are typically brief and more irregular than seizures.  Subarachnoid hemorrhage may result in syncope. Often this is in combination with sudden, severe headache. It may occur as a result of a ruptured aneurysm or head trauma.

Heat syncope occurs when heat exposure causes decreased blood volume and peripheral vasodilatation. Position changes, especially during vigorous exercise in the heat, may lead to decreased blood flow to the brain. 

Some psychological conditions (anxiety disorder, somatic symptom disorder, conversion disorder) may cause symptoms resembling syncope. A number of psychological interventions are available. Low blood sugar can be a rare cause of syncope.

A medical history, physical examination, and electrocardiogram (ECG) are the most effective ways to determine the underlying cause of syncope.

Computed tomography (CT) is generally not required unless specific concerns are present. Treatment depends on the underlying cause. Those who are considered at high risk following investigation may be admitted to hospital for further monitoring of the heart.

A hemoglobin count may indicate anemia or blood loss. However, this has been useful in only about 5% of people evaluated for fainting.

Differential diagnosis.

Other diseases which mimic syncope include seizure, low blood sugar, and certain types of stroke. While these may appear as "fainting", they do not fit the strict definition of syncope being a sudden reversible loss of consciousness due to decreased blood flow to the brain.[9]

Management. Management of syncope focuses on treating the underlying cause. This can be challenging as the underlying cause is unclear in half of all cases

Recommended acute treatment of vasovagal and orthostatic (hypotension) syncope involves returning blood to the brain by positioning the person on the ground, with legs slightly elevated or sitting leaning forward and the head between the knees for at least 10–15 minutes, preferably in a cool and quiet place. For individuals who have problems with chronic fainting spells, therapy should focus on recognizing the triggers and learning techniques to keep from fainting. At the appearance of warning signs such as lightheadedness, nausea, or cold and clammy skin, counter-pressure maneuvers that involve gripping fingers into a fist, tensing the arms, and crossing the legs or squeezing the thighs together can be used to ward off a fainting spell. After the symptoms have passed, sleep is recommended. Lifestyle modifications are important for treating people experiencing repeated syncopal episodes. Avoiding triggers and situations where loss of consciousness would be seriously hazardous (operating heavy machinery, commercial pilot, etc.) has been shown to be effective.

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Seizures.

A seizure is a sudden, uncontrolled electrical disturbance in the brain. It can cause changes in your behavior, movements or feelings, and in levels of consciousness. Having two or more seizures at least 24 hours apart that aren't brought on by an identifiable cause is generally considered to be epilepsy.

There are many types of seizures, which range in symptoms and severity. Seizure types vary by where in the brain they begin and how far they spread. Most seizures last from 30 seconds to two minutes. A seizure that lasts longer than five minutes is a medical emergency.

Seizures are more common than you might think. Seizures can happen after a stroke, a closed head injury, an infection such as meningitis or another illness. Many times, though, the cause of a seizure is unknown.

Most seizure disorders can be controlled with medication, but management of seizures can still have a significant impact on your daily life. The good news is that you can work with your doctor to balance seizure control and medication side effects.

Symptoms. With a seizure, signs and symptoms can range from mild to severe and vary depending on the type of seizure. Seizure signs and symptoms may include: temporary confusion, a staring spell, uncontrollable jerking movements of the arms and legs, loss of consciousness or awareness and cognitive or emotional symptoms, such as fear, anxiety.

Generally, seizures could either be focal or generalized, based on how and where abnormal brain activity begins. Seizures may also be classified as unknown onset, if how the seizure began isn't known.

Focal seizures. These seizures result from abnormal electrical activity in one area of your brain. Focal seizures can occur with or without loss of consciousness:

Focal seizures with impaired awareness. These seizures involve a change or loss of consciousness or awareness that feels like being in a dream. You may seem awake, but you stare into space and do not respond normally to your environment or you perform repetitive movements. These may include hand rubbing, mouth movements, repeating certain words or walking in circles. You may not remember the seizure or even know that it occurred.

Focal seizures without loss of consciousness. These seizures may alter emotions or change the way things look, smell, feel, taste or sound, but you don't lose consciousness. You may suddenly feel angry, joyful or sad. Some people have nausea or unusual feelings that are difficult to describe. These seizures may also result in difficulty speaking, involuntary jerking of a body part, such as an arm or a leg, and spontaneous sensory symptoms such as tingling, dizziness and seeing flashing lights.

Generalized seizures. Seizures that appear to involve all areas of the brain are called generalized seizures. Different types of generalized seizures include:

Absence seizures. Previously known as petit mal seizures, often occur in children and are characterized by staring into space or by subtle body movements, such as eye blinking or lip smacking. They usually last for five to 10 seconds but may happen up to hundreds of times per day. These seizures may occur in clusters and cause a brief loss of awareness.

Tonic seizures. These cause stiffening of your muscles. These seizures usually affect muscles in your back, arms and legs and may cause you to lose consciousness and fall to the ground.

Atonic seizures. Atonic seizures, also known as drop seizures, cause a loss of muscle control, which may cause you to suddenly collapse, fall down or drop your head.

Clonic seizures. Clonic seizures are associated with repeated or rhythmic, jerking muscle movements. These seizures usually affect the neck, face and arms on both sides of the body.

Myoclonic seizures. Myoclonic seizures usually appear as sudden brief jerks or twitches of your arms and legs. There is often no loss of consciousness.

Tonic-clonic seizures. Tonic-clonic seizures, previously known as grand mal seizures, are the most dramatic type of epileptic seizure and can cause an abrupt loss of consciousness, body stiffening and shaking, and sometimes loss of bladder control or biting your tongue. They may last for several minute.

Seek immediate medical help if any of the following occurs: the seizure lasts more than five minutes, breathing or consciousness doesn't return after the seizure stops, a second seizure follows immediately, you have a high fever, you're experiencing heat exhaustion, you're pregnant, you have diabetes or you've injured yourself during the seizure. If you experience a seizure for the first time, seek medical advice.

Causes. Nerve cells (neurons) in the brain create, send and receive electrical impulses, which allow the brain's nerve cells to communicate. Anything that disrupts these communication pathways can lead to a seizure. Some types of seizure disorders may be caused by genetic mutations.

The most common cause of seizures is epilepsy. But not every person who has a seizure has epilepsy. Sometimes seizures may be caused or triggered by: high fever, which can be associated with an infection such as meningitis, lack of sleep, low blood sodium (hyponatremia), which can happen with diuretic therapy, medications, such as certain pain relievers, antidepressants or smoking cessation therapies, that lower the seizure threshold, head trauma that causes an area of bleeding in the brain, abnormalities of the blood vessels in the brain, stroke and brain tumor. Others are: use of illegal or recreational drugs, such as amphetamines or cocaine, alcohol misuse, during times of withdrawal or extreme intoxication and COVID-19 virus infection

Complications.

Having a seizure can sometimes lead to circumstances that are dangerous for you or others. You might be at risk of: falling, drowning, car accidents, pregnancy complications ( Seizures during pregnancy pose dangers to both mother and baby, and certain anti-epileptic medications increase the risk of birth defects. If you have epilepsy and plan to become pregnant, work with your doctor so that he or she can adjust your medications and monitor your pregnancy, as needed) and emotional health issues. People with seizures are more likely to have psychological problems, such as depression and anxiety. Problems may be a result of difficulties dealing with the condition itself as well as medication side effects.

Diagnosis

After a seizure, your doctor will thoroughly review your symptoms and medical history. Several tests may be ordered to determine the cause of your seizure and evaluate how likely it is that you'll have another one.

Tests may include: A neurological exam. Blood tests for example blood sugar levels and look for signs of infections. Lumbar puncture. If your doctor suspects an infection as the cause of a seizure, you may need to have a sample of cerebrospinal fluid removed for testing. An electroencephalogram (EEG). In this test, doctors attach electrodes to your scalp with a paste-like substance. The electrodes record the electrical activity of your brain.

Imaging tests may include: Magnetic resonance imaging (MRI) and Computerized tomography (CT) scan.

Treatment.

Not everyone who has one seizure will have another one, and because a seizure can be an isolated incident, your doctor may not decide to start treatment until you've had more than one.

The optimal goal in seizure treatment is to find the best possible therapy to stop seizures, with the fewest side effects.

Medication

Treatment for seizures often involves the use of anti-seizure medications. There are many different options for anti-seizure medication. The goal of medication is to find the medicine that works best for you and that causes the fewest side effects. In some cases, your doctor might recommend more than one medication.

Your doctor will consider your condition, your frequency of seizures, your age and other factors when choosing which medication to prescribe. Your doctor will also review any other medications you may be taking, to ensure that the anti-epileptic medications won't interact with them.

Dietary therapy. Following a diet that's high in fat and very low in carbohydrates, known as a ketogenic diet, can improve seizure control.

Surgery. If other treatments aren't effective, surgery may be an option. The goal of surgery is to stop seizures from happening. Surgery works best for people who have seizures that always originate in the same place in the brain.

Lifestyle and home remedies

Here are some steps you can take to help with seizure control:

Take medication correctly. Don't adjust the dosage before talking to your doctor. If you feel that your medication should be changed, discuss it with your doctor.

Get enough sleep. Lack of sleep can trigger seizures. Be sure to get adequate rest every night.

Wear a medical alert bracelet. This will help emergency personnel know how to treat you correctly if you have another seizure.

Be active. Exercising and being active may help keep you physically healthy and reduce depression. Make sure to drink enough water and rest if you get tired during exercise.

Make healthy life choices. Managing stress, limiting alcoholic beverages and avoiding cigarettes all factor into a healthy lifestyle.

Personal safety

Seizures don't usually result in serious injury, but if you have recurrent seizures, injury is a possibility. These steps can help you avoid injury during a seizure:

Take care near water. Don't swim alone or relax in a boat without someone nearby.

Wear a helmet for protection during activities such as bike riding or sports participation.

Take showers instead of baths, unless someone is near you.

Modify your furnishings. Pad sharp corners, buy furniture with rounded edges and choose chairs that have arms to keep you from falling off of them. Consider carpet with thick padding to protect you if you do fall.

Seizure first aid.

To help someone during a seizure, take these steps: Carefully roll the person onto one side. Place something soft under his or her head. Loosen tight neckwear. Avoid putting your fingers or other objects in the person's mouth. Don't try to restrain someone having a seizure. Clear away dangerous objects if the person is moving. Stay with the person until medical personnel arrive. Observe the person closely so that you can provide details on what happened. Time the seizure. Stay calm.