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IAEM Syncope
IAEM Clinical Guideline Management of syncope in the emergency department Version 1 April, 2019 Authors: Dr Áine Mitchell, in collaboration with Dr Rosa McNamara, Professor Rose Anne Kenny and the IAEM Guideline Development Committee. DISCLAIMER IAEM recognises that patients, their situations, Emergency Departments and staff all vary. These guidelines cannot cover all clinical scenarios. The ultimate responsibility for the interpretation and application of these guidelines, the use of current information and a patient's overall care and wellbeing resides with the treating clinician. GLOSSARY OF TERMS AAA: Abdominal aortic aneurysm AFib: Atrial fibrillation ARVC: Arrythmogenic right ventricular cardiomyopathy AV: Atrioventricular βHCG: Beta human chorionic gonadotropin BP: Blood pressure BSL: Blood sugar level CCF: Congestive cardiac failure CM: Cardiomyopathy ECG: Electrocardiogram ED: Emergency Department EF: Ejection fraction ESC: European Society of Cardiology FHx: Family history GI: Gastrointestinal GP: General practitioner HCT: Haematocrit HOCM: Hypertrophic obstructive cardiomyopathy Hx: History IAEM: Irish Association for Emergency Medicine ICD: Implanted cardioverter defibrillator IHD: Ischaemic heart disease MI: Myocardial Infarction OPD: Out-patient department PCM: Physical counter-pressure manoeuvres PE: Pulmonary embolus PMHx: Past Medical History PPM: Permanent pacemaker RSA: Road safety authority SAH: Sub-arachnoid haemorrhage SBP: Systolic blood pressure SCD: Sudden cardiac death SVT: Supra-ventricular tachycardia TIA: Transient ischaemic attack T-LOC: Transient loss of consciousness VT: Ventricular tachycardia WPW: Wolff-Parkinson-White 2 IAEM CG: Management of syncope in the emergency department Version 1 April 2019 INTRODUCTION Syncope is defined as a transient loss of consciousness (T-LOC) due to cerebral hypoperfusion. It is characterised by a rapid onset, short duration and spontaneous complete recovery. -
Evaluation of Peripheral Microcirculation Improvement of Foot After Tarsal Tunnel Release in Diabetic Patients by Transcutaneous Oximetry
EVALUATION OF PERIPHERAL MICROCIRCULATION IMPROVEMENT OF FOOT AFTER TARSAL TUNNEL RELEASE IN DIABETIC PATIENTS BY TRANSCUTANEOUS OXIMETRY EMILIO TRIGNANO, M.D., Ph.D.,1,2 NEFER FALLICO, M.D.,3* HUNG-CHI CHEN, M.D., M.H.A., F.A.C.S.,2 MARIO FAENZA, M.D.,1 ALFONSO BOLOGNINI, M.D.,1 ANDREA ARMENTI, M.D.,3 FABIO SANTANELLI DI POMPEO, M.D.,4 CORRADO RUBINO, M.D,5 and GIAN VITTORIO CAMPUS, M.D.1 Background: According to recent studies, peripheral nerve decompression in diabetic patients seems to not only improve nerve function, but also to increase microcirculation; thus decreasing the incidence of diabetic foot wounds and amputations. However, while the postop- erative improvement of nerve function is demonstrated, the changes in peripheral microcirculation have not been demonstrated yet. The aim of this study is to assess the degree of microcirculation improvement of foot after the tarsal tunnel release in the diabetic patients by using transcutaneous oximetry. Patients and methods: Twenty diabetic male patients aged between 43 and 72 years old (mean age 61.2 years old) suffering from diabetic peripheral neuropathy with superimposed nerve compression underwent transcutaneous oximetry (PtcO2) before and after tarsal tunnel release by placing an electrode on the skin at the level of the dorsum of the foot. Eight lower extremities presented diabetic foot wound preoperatively. Thirty-six lower extremities underwent surgical release of the tibialis posterior nerve only, whereas four lower extremities underwent the combined release of common peroneal nerve, anterior tibialis nerve, and poste- rior tibialis nerve. Results: Preoperative values of transcutaneous oximetry were below the critical threshold, that is, lower than 40 mmHg (29.1 6 5.4 mmHg). -
Influence of Experimental Diabetes on the Microcirculation of Injured Peripheral Nerve Functional and Morphological Aspects
Influence of Experimental Diabetes on the Microcirculation of Injured Peripheral Nerve Functional and Morphological Aspects James M. Kennedy and Douglas W. Zochodne Regeneration of diabetic axons has delays in onset, sumption of regenerating axons and cellular elements rate, and maturation. It is possible that microangiopa- during repair. For example, rises in blood flow, or hyper- thy of vasa nervorum, the vascular supply of the periph- emia, may be mediated by vasodilation of the extrinsic eral nerve, may render an unfavorable local vasa nervorum (2) by neuropeptides (notably calcitonin environment for nerve regeneration. We examined local gene-related peptide [CGRP], substance P, and vasoactive nerve blood flow proximal and distal to sciatic nerve intestinal peptide [VIP]) and mast cell-derived histamine. transection in rats with long-term (8 month) experi- Macrophage- and endothelial-derived nitric oxide (NO) mental streptozotocin diabetes using laser Doppler flowmetry and microelectrode hydrogen clearance po- also likely augments nerve blood flow at the injury site larography. We then correlated these findings, using in through vasodilation. At later stages of regeneration and vivo perfusion of an India ink preparation, by outlining repair, extensive neoangiogenesis may maintain a persis- the lumens of microvessels from unfixed nerve sections. tent hyperemic state (3). Revascularization from angiogen- There were no differences in baseline nerve blood flow esis into a peripheral nerve graft often precedes between diabetic and nondiabetic uninjured nerves, and regenerating axons (4), with fibers near blood vessels vessel number, density, and area were unaltered. After having the fastest regeneration rates (5). transection, there were greater rises in blood flow in Regenerative success in diabetes is impaired as a result proximal stumps of nondiabetic nerves than in diabetic of defects in the onset of regeneration (6), in elongation animals associated with a higher number, density, and caliber of epineurial vessels. -
Neurocardiogenic Syncope and Associated Conditions: Insight Into Autonomic Nervous System Dysfunction
Türk Kardiyol Dern Arş - Arch Turk Soc Cardiol 2013;41(1):75-83 doi: 10.5543/tkda.2013.44420 75 Neurocardiogenic syncope and associated conditions: insight into autonomic nervous system dysfunction Nörokardiyojenik senkop ve ilişkili durumlar: Otonomik sinir sistemi işlev bozukluğuna bir bakış Antoine Kossaify, M.D., Kamal Kallab, M.D. Department of Syncope and Electrophysiology, ND Secours/USEK University Hospital, Byblos, Lebanon Summary– Neurocardiogenic syncope is known to be asso- Özet– Nörokardiyojenik senkopun mekanizması hala tam ola- ciated with autonomic nervous system dysfunction, although rak aydınlatılamamasına ragmen otonom sinir sistemi işlev the mechanism has not been entirely elucidated. In this study, bozukluğu ile ilişkili olduğu bilinmektedir. Bu yazıda nörokardi- we sought to highlight the pathogenic role of the autonomic yojenik senkop patogenezinde otonom sinir sisteminin rolünü nervous system in neurocardiogenic syncope and to review destekleyen en göze çarpıcı konuları araştırırken, temelinde the associated co-morbidities known to have a dysautonomic otonom sinir sistemi bozukluğunun olduğu bilinen komorbid basis. Herein we discuss migraine, orthostatic hypotension, durumları da gözden geçidik. Bu amaçla otonom sinir siste- postural orthostatic tachycardia syndrome, endothelial dys- minin patogenezdeki rolü ve klinik çıkarımları üzerine odak- function, chronic fatigue syndrome, and carotid sinus hyper- lanarak migren, ortostatik hipotansiyon, postüral ortostatik sensitivity with a focus on the pathogenic role of the autonom- taşikardi sendromu, endotel işlev bozukluğu, kronik yorgunluk ic nervous system and any consecutive clinical implications. sendromu ve karotis sinüs hipersensitivitesi tartışıldı. Tilt testi Other conditions, such as pre-syncopal heart rate acceleration sırasında ortaya çıkabilen senkop öncesi kalp atımlarında hız- and/or instability and pre-syncopal breathing instability, which lanma ve/veya instabilite ve senkop öncesi instabil solunum occur during a tilt test, are discussed in the same perspective. -
O'malley-MS-1969.Pdf
DEVELOPMENT OF COLLATERAL CIRCULATION IN PARTIALLY EEVASCULARIZED FELINE SCIATIC NERVE 31 JOHN FRANCIS O'KALLEY A THESIS Submitted to the Faculty of the Graduate School of the Creighton University in Partial Fulfillment of the Requirements for the Degree of Master of Science in the Department of Anatomy Omaha, 1 969 V ACKNOWLEDGMENTS I am deeply indebted ana grateful to my advisor, Doctor Julian J. Baumel, for his patience, unselfish assistance, and constructive criticism throughout this investigation. I also wish to express my appreciation to Dr. R. Dale Smith for his valuaole assistance, to Dr. John 3arton for his help with the photogranhie representations, to Mrs. Edith Witt for the expert typing of the final manuscript, and to all the members of the faculty of the Anatomy Department for the excellent graduate training I have received. I especially wish to acknowledge my wife, Helen, for her understanding and perseverance through out my graduate studies, and it is to her that I dedicate this t h e s i s . vi TABLE OF CONTENTS A C KN OWLE DG ï T E N T S .......... LIST OF ILLUSTRATIONS Chapter I. INTRODUCTION ....................................... 1 II. HISTORY ............................................ 1+ Vasa Nervorum Collateral Circulation III. MATERIALS AND METHODS ............................ 10 Surgical Exposure Devascularization Vascular Injection Clearing IV. O B S E R V A T I O N S ....................................... l£ Sciatic Nerve - Anatomy Vascular Supply of Sciatic Nerve Art e r i e s Veins Development of Collateral Circulation Three-Day ‘/ascular Pattern Six-Seven Day Vascular Patterns Fourteen-Seventeen Day Vascular Patterns V. D I S C U S S I O N ...................................... -
Syncope in Adults: Systematic Review and Proposal of a Diagnostic and Therapeutic Algorithm
International Journal of Cardiology 162 (2013) 149–157 Contents lists available at SciVerse ScienceDirect International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard Review Syncope in adults: Systematic review and proposal of a diagnostic and therapeutic algorithm Salvatore Rosanio a,⁎, Ernst R. Schwarz b, David L. Ware c, Antonio Vitarelli d a University of North Texas Health Science Center (UNTHSC) Department of Internal Medicine, Division of Cardiology 855 Montgomery Street 76107 Fort Worth, TX, United States b Cardiology Division, Cedars Sinai Medical Center, Los Angeles, CA, United States c Cardiology Division, University of Texas Medical Branch, Galveston, TX, United States d Cardio-Respiratory Department, La Sapienza University, Rome, Italy article info abstract Article history: This review aims to provide a practical and up-to-date description on the relevance and classification of syncope Received 19 June 2011 in adults as well as a guidance on the optimal evaluation, management and treatment of this very common clin- Received in revised form 28 October 2011 ical and socioeconomic medical problem. We have summarized recent active research and emphasized the value Accepted 24 November 2011 for physicians to adhere current guidelines. A modern management of syncope should take into account 1) use of Available online 20 December 2011 risk stratification algorithms and implementation of syncope management units to increase the diagnostic yield and reduce costs; 2) early implantable loop recorders rather than late in the evaluation of unexplained syncope; Keywords: fi Syncope and 3) isometric physical counter-pressure maneuvers as rst-line treatment for patients with neurally- Pacing mediated reflex syncope and prodromal symptoms. -
STARS Reflex Syncope (VVS) Booklet.Indd
Reflex Syncope (Vasovagal Syncope) Working together with individuals, families and medical professionals to off er support and information on syncope and refl ex anoxic seizures www.stars.org.ukRegistered Charity No. 1084898 Registered Charity No. 1084898 Glossary of terms Refl ex syncope Refl ex syncope is a transient condition resulting from intermittent dysfunction of the autonomic nervous Contents system, which regulates blood pressure and heart rate. 12-lead ECG What is refl ex 12-lead electrocardiogram (ECG) is used to record heart syncope? rhythms whilst in hospital. Heart rhythm monitor What are the Heart rhythm monitors are used to record heart rhythms symptoms? for up to a week whilst away from hospital. ILR How do I obtain a Implantable loop recorder (ILR) is a small thin device diagnosis? inserted under the skin to record heart rhythms. The device can remain in place for up to three years. What should I do if I Tilt table test feel dizzy or faint? A tilt table test is an autonomic test used to induce an attack whilst connected to heart and blood pressure What should my monitors. friends/family do Collapse if I faint? Abrupt loss of postural control Blackout/T-LoC What can I do to Transient loss of consciousness without neurological prevent syncope defi cit attacks? Syncope T-LoC due to transient global impairment of cerebral Are there any other perfusion treatments? Epilepsy Repeated episodes of excessive asynchronous discharge Driving and refl ex of cortical neurones leading to a clinical event syncope Psychogenic blackouts A cause of apparent blackouts without evidence of Flying and refl ex syncope or epilepsy syncope Fall Patient goes down freely under the infl uence of gravity Misdiagnosis TIA TIA (transient ischaemic attack) is caused by a temporary disruption in the blood supply to part of the brain (also known as a mini stroke) 2 What is reflex syncope? SYNCOPE (sin-co-pee) is a medical term for a This booklet is blackout caused by a sudden lack of blood supply designed for to the brain. -
Reflex Syncope in Children and Adolescents, Its Tclinical Characteristics and Syndromes, the Approach to Diagnosis, and Finally Treatment
Congenital heart disease REFLEX SYNCOPE IN CHILDREN AND Heart: first published as 10.1136/hrt.2003.022996 on 13 August 2004. Downloaded from ADOLESCENTS 1094 Wouter Wieling, Karin S Ganzeboom, J Philip Saul Heart 2004;90:1094–1100. doi: 10.1136/hrt.2003.022996 his article will address the epidemiology of reflex syncope in children and adolescents, its Tclinical characteristics and syndromes, the approach to diagnosis, and finally treatment. c EPIDEMIOLOGY Syncope can be defined as a temporary loss of consciousness and postural tone secondary to a lack of adequate cerebral blood perfusion. The incidence of syncope coming to medical attention appears to be clearly increased in two age groups—that is, in the young and in the old (fig 1).1 An incidence peak occurs around the age of 15 years, with females having more than twice the incidence of males.12 Syncope is an infrequent occurrence in adults. The incidence of syncope progressively increases over the age of about 40 years to become high in the older age groups. A lower peak occurs in older infants and toddlers, most commonly referred to as ‘‘breath-holding spells’’.3 The incidence of syncope in young subjects coming to medical attention varies from approximately 0.5 to 3 cases per 1000 (0.05–0.3%).2 Syncopal events which do not reach medical attention occur much more frequently. In fact, the recently published results of a survey of students averaging 20 years of age demonstrated that about 20% of males and 50% of females report to have experienced at least one syncopal episode.4 By comparison, the prevalence of seizures in a similar age group is about 5 per 1000 (0.5%)5 and cardiac syncope (that is, cardiac arrhythmias or structural heart disease) is even far less common. -
Syncope (Fainting) Information Sheet
Sunshine Coast Hospital and Health Service Syncope (fainting) information sheet • Orthostatic: These episodes are often caused by a sudden drop in blood pressure upon standing. These episodes can be caused by a number of factors including dehydration, some medications or even standing up too quickly. • Reflex/Vasovagal: These episodes are often caused by a disturbance in either the heart rate or blood pressure that is controlled by nerves in the brain. Often patients may have warning signs (feeling dizzy, unsteady on feet) prior to these events occurring. • Other: Even after extensive investigations we are What is Syncope? unable to determine a cause for these events in up Syncope is a broad medical term used for to 20 per cent of people. fainting or loss of consciousness due to a Treatment temporary decline in blood flow to the brain. In the emergency department, the person will be closely monitored and any injuries they may have Blood vessels continually adjust their width sustained will be treated. The person may have to ensure a constant blood pressure. For blood tests taken to assess a number of factors and these may assist the doctors in determining why this instance, the vessels constrict (tighten) when person has experienced this episode. we stand up to counteract the effects of gravity. Some people will need to stay in hospital for observation, particularly if they have more than Temporary, low blood pressure can be caused one episode or if the episode occurs without any by various events that prompt blood vessels warning signs. The person may be required to have to dilate (expand), including extreme heat, any number of the following tests: emotional distress or pain. -
Dictionary of Epilepsy
DICTIONARY OF EPILEPSY PART I: DEFINITIONS .· DICTIONARY OF EPILEPSY PART I: DEFINITIONS PROFESSOR H. GASTAUT President, University of Aix-Marseilles, France in collaboration with an international group of experts ~ WORLD HEALTH- ORGANIZATION GENEVA 1973 ©World Health Organization 1973 Publications of the World Health Organization enjoy copyright protection in accord ance with the provisions of Protocol 2 of the Universal Copyright Convention. For rights of reproduction or translation of WHO publications, in part or in toto, application should be made to the Office of Publications and Translation, World Health Organization, Geneva, Switzerland. The World Health Organization welcomes such applications. PRINTED IN SWITZERLAND WHO WORKING GROUP ON THE DICTIONARY OF EPILEPSY1 Professor R. J. Broughton, Montreal Neurological Institute, Canada Professor H. Collomb, Neuropsychiatric Clinic, University of Dakar, Senegal Professor H. Gastaut, Dean, Joint Faculty of Medicine and Pharmacy, University of Aix-Marseilles, France Professor G. Glaser, Yale University School of Medicine, New Haven, Conn., USA Professor M. Gozzano, Director, Neuropsychiatric Clinic, Rome, Italy Dr A. M. Lorentz de Haas, Epilepsy Centre "Meer en Bosch", Heemstede, Netherlands Professor P. Juhasz, Rector, University of Medical Science, Debrecen, Hungary Professor A. Jus, Chairman, Psychiatric Department, Academy of Medicine, Warsaw, Poland Professor A. Kreindler, Institute of Neurology, Academy of the People's Republic of Romania, Bucharest, Romania Dr J. Kugler, Department of Psychiatry, University of Munich, Federal Republic of Germany Dr H. Landolt, Medical Director, Swiss Institute for Epileptics, Zurich, Switzerland Dr B. A. Lebedev, Chief, Mental Health, WHO, Geneva, Switzerland Dr R. L. Masland, Department of Neurology, College of Physicians and Surgeons, Columbia University, New York, USA Professor F. -
Hyperglycemia, Lumbar Plexopathy and Hypokalemic Rhabdomyolysis Complicating Conn's Syndrome
Hyperglycemia, Lumbar Plexopathy and Hypokalemic Rhabdomyolysis Complicating Conn's Syndrome Chi-Ping Chow, Christopher J. Symonds and Douglas W. Zochodne ABSTRACT: Background: Lumbosacral plexopathy is a complication of diabetes mellitus. Conn's syndrome from an aldosterone secreting adenoma may be associated with hypokalemia and rhabdomy olysis but mild hyperglycemia also usually occurs. Methods: Case description. Results: A 70-year-old male diagnosed as having Conn's syndrome, hypokalemia and mild hyperglycemia developed rhab domyolysis and lumbar plexopathy as a presenting feature of his hyperaldosteronism. His rhadbdomy- olysis rapidly cleared following correction of hypokalemia but recovery from the plexopathy occurred slowly over several months. Definite resection of the aldosterone secreting adenomas reversed the hyperglycemia. Conclusions: Our patient developed lumbar plexopathy resembling that associated with diabetes mellitus despite the presence of only mild and transient hyperglycemia. RESUME: Hyperglycemic, plexopathie lombaire et rhabdomyolyse hypokaliemique compliquant le syn drome de Conn. Introduction: La plexopathie lombosacree est une complication du diabete. Le syndrome de Conn du a un adenome secrefant de l'aldosterone peut etre associe a une hypokaliemie et a un rhabdomyolyse, mais une legere hyperglycemic peut aussi etre presente. Methode: Description d'un cas. Resultats: Un patient age de 70 ans porteur d'un syndrome de Conn, d'une hypokaliemie et d'une legere hyperglycemic a developpe une rhab domyolyse et une plexopathie lombaire comme manifestation initiale de son hyperaldosteronisme. La rhabdomyol yse s'est resolue rapidement suite a la correction de l'hypokaliemie, mais la guerison de sa plexopathie a pris plusieurs mois. La resection definitive de l'adenome secrefant de l'aldosterone a fait disparaitre l'hyperglycemie. -
Bone Marrow-Derived Stem Cells: a Mixed Blessing in the Multifaceted World of Diabetic Complications
Mangialardi, G., & Madeddu, P. (2016). Bone Marrow-Derived Stem Cells: A Mixed Blessing in the Multifaceted World of Diabetic Complications. Current diabetes reports, 16(5), [43]. https://doi.org/10.1007/s11892-016-0730-x Publisher's PDF, also known as Version of record License (if available): CC BY Link to published version (if available): 10.1007/s11892-016-0730-x Link to publication record in Explore Bristol Research PDF-document This is the final published version of the article (version of record). It first appeared online via Current Medicine Group at http://dx.doi.org/ 10.1007/s11892-016-0730-x. Please refer to any applicable terms of use of the publisher. University of Bristol - Explore Bristol Research General rights This document is made available in accordance with publisher policies. Please cite only the published version using the reference above. Full terms of use are available: http://www.bristol.ac.uk/red/research-policy/pure/user-guides/ebr-terms/ Curr Diab Rep (2016) 16: 43 DOI 10.1007/s11892-016-0730-x IMMUNOLOGY AND TRANSPLANTATION (L PIEMONTI AND V SORDI, SECTION EDITORS) Bone Marrow-Derived Stem Cells: a Mixed Blessing in the Multifaceted World of Diabetic Complications Giuseppe Mangialardi1 & Paolo Madeddu1 Published online: 30 March 2016 # The Author(s) 2016. This article is published with open access at Springerlink.com Abstract Diabetes is one of the main economic burdens in Introduction health care, which threatens to worsen dramatically if preva- lence forecasts are correct. What makes diabetes harmful is the Diabetes mellitus (DM) is a family of metabolic disorders multi-organ distribution of its microvascular and characterized by high blood glucose levels.