晕厥的诊断与处理

晕厥的诊断与处理Syncope晕厥的诊断与处理晕厥的概念晕厥的诊断晕厥的治疗一.晕厥的一般概念什么是晕厥?突发、短暂的意识丧失伴晕倒—突然脑灌注不足与猝死的不同能—“醒过来”DefinitionofSyncopeSyncopeisasymptom,thedefiningclinicalcharacteristicsofwhichare:1.Transient2.Self-limitedlossofconsciousnessleadingtofalling3.Onsetisrelativelyrapid4.Recoveryisspontaneous,complete,andusuallyprompt.症状四大特点临床症状:自发的意识丧失快速性有先兆自限性、完全恢复（与猝死的差别）晕厥的原因(晕厥门诊)OrthostaticCardiacArrhythmiaStructuralCardio-Pulmonary*1•Vasovagal•CarotidSinus•SituationalCoughPost-micturition2•DrugInduced•ANSFailurePrimarySecondary3•BradySicksinusAVblock•TachyVTSVT•LongQTSyndrome4•AorticStenosis•HOCM•PulmonaryHypertension5Cerebro-vascularNeurally-MediatedUnknownCause=18%56%2%20%3%1%AlboniP,etal.JACC2001;37:1921-1928•StealSyndrome•TIA•EpilepsyClassificationoftransientlossofconsciousnessSyncope1.Neurally-mediatedreflexsyncopalsyndromes2.Cardiacarrhythmiaasprimarycauses3.Structuralcardiacorcardiopulmonarydiseases4.CerebrovascularNon-syncopalattacks1.Withimpairmentorlossofconsciousness2.WithoutlossofconsciousnessCausesofSyncope1.Neurally-mediatedreflexsyncopalsyndromesa.Vasovagalfaintb.Carotidsinussyncopec.Situationalfaint:AcutehaemorryagingCoughing,sneezingGastrointestinalstimulation(swallowing,defacation,visceralpain)Micturation(Post-micturation)Post-exerciseOther(e.g.Brassinstrumentplaying,weighlifting,post-prandial)D.GlossopharyngealandtrigeminalneuralgiaCausesofSyncope(cont.)2.OrthostatichypotensionAutonomicfailurePrimaryautonomicfailuresyndromes(e.g.pureautonomicfailure,multiplesystematrophy,Parkison’sdiseasewithautonomicfailure)Secondaryautonomicfailuresyndrome(e.g.diabeticneuropathy,amyloidneuropathy)Post-exercise,post-prandialDrugsandalcoholVolumedepletionHaemorryaging,diarrhea,Addison’sdiseaseOrthostaticSyncopeOrthostaticSyncopeisdiagnosedwhenthereisdocumentationoforthostatichypotensionassociatedwithsyncopeorpresyncope.OrthostaticBpmeasurementsarerecommendedafter5minoflyingsupine,followedbyeachminormoreoften,afterstandingfor3min.Measurementsmaybecontinuedlonger,ifBpisstillfallingat3min.Ifpatientdoesnottoleratestandingforthisperiod,thelowestSpduringtheuprightpostureshouldberecorded.AdecreaseinSp≥20mmHgoradecreaseofSpto90mmHgisdefinedasorthostatichypotensionregardlessofwhetherornotsymptomsoccureCausesofSyncope(cont.)3.Cardiacarrythmiasasprimarycause1.Sinusnodedisfunction2.Atrioventricularconductionsystemdisease3.PSVTandVT4.Inheritedsyndromes(longQTsyndrome,Brugadasyndrome)5.Implanteddevice(pacemaker,ICD)malfunctionordrug-inducedproarrythmiasCausesofSyncope(cont.)4.StructuralcardiacorcardiopulmonarydiseasesCardiacvalvulardiseasea.AMI/ischemiab.Obstructivecardiomyopathyc.Atrialmyxomad.Acuteaorticdissectione.Pericardialdisease/tamponadef.Pulmonaryembolus/pulmonryhypertensiong.Obstructivecardiacdisease5.CerebrovascularVascularstealsyndromesCausesofNon-syncopeAttacks(Commonlymisdiagnosedassyncope)1.Disorderswithimpairmentorlossofconsciousnessa.Metabolicdisorders(hypoglycaemia,hypoxia,hyperventilationwithhypocapniab.Epilepsyc.Intoxicationd.Vertebro-basilarTIA2.Disordersresemblingsyncopewithoutlossofconsciousnessa.Cataplexyb.Dropattacksc.Psychogenic“syncope”(somatizationdisorders)d.TIAofcarotidorigin二.晕厥的诊断神经科医生心脏科医生Initialevaluationimportanthistoricalfeatures1、QuestionsaboutcircumstancesjusttoattackPosition(supine,sittingorstanding)Activity(supine,duringorafterexercise)Situation(urination,defecation,coughorswallowing)Predisposingfactors(e.g.,crowdedorwarmplaces,prolongedstanding,post-prandialperiod)Precipitatingevents(e,g.,fear,intensepain,neckmovements)2、QuestionsaboutonsetofattackNausea,vomiting,feelingofcold,sweating,aura,paininneckorshoulders3、Questionsaboutattack(eyewitness)Skincolour(pallor,cyanotic)DurationoflossofconsciousnessMovements(tonic-clonic,etc)Tonguebiting5、QuestionsaboutendofattackNausea,vomiting,diaphoresis,feelingofcold,confusion,muscleaches,skincolour,wounds6、QuestionsaboutbackgroundNumberanddurationofsyncopesFamilyhistoryofarrhyhmogenicdiseasePresenceofcardiacdiseaseNeurologicalhistory(parkinsonism,epilepsy,narcolepsy)Internalhistory(diabetes,etc.)Medication(hypotensiveandantidepressantagents)InitialevaluationimportanthistoricalfeaturesInitialevaluationDiagnosticcriterionVasovagalsyncopeisdiagnosedifprecipitatingeventssuchasfear,severepain,emotionaldistress,instrumentationandprolongedstandingareassociatedwithtypicalprodromalsymptoms.Situationalsyncopeisdiagnosedifsyncopeoccursduringorimmediatelyafterurination,defecation,coughorswallowing.Orthostaticsyncopeindiagnosedwhenthereisadocumentationoforthostatichypotensionassociatedwithsyncopeorpresyncope.InitialevaluationECGdiagnosticcriteriaSyncopeduetocardiacarrhythmiaisdiagnosedincaseof:Symptomaticsinusbradycardia40beats/minorrepetitivesinoatrialblocksOrsinuspauese3sMobitzII2ndor3rddegreeatrioventricularblockAlternatingleftandrightbundlebranchblockRapidparoxysmaltachycardiaPacemakermalfunctionwithcardiacpausesInitialevaluationECGdiagnosticcriteriaSyncopeduetocardiacischemiaisdiagnosedwhensymptomsarepresentwithECGevidenceofacutemyocardialischaemi