Syncope toolkit
Syncope is very common and will affect 42% of people during their lifetime
Case history: Non-haemodynamic collapse / Psychogenic Pseudosyncope (PPS)
History
A 19 year old boy attends with his mother with a history of multiple syncopal episodes in the previous 24 months. They report frequent and witnessed episodes of syncope with several episodes occurring in a single day. There are no associated triggers or warnings of the attacks. He has no significant past medical history but also reports symptoms of body aches, fatigue and generalised weakness. You note that he has already undergone extensive investigations under a paediatrician 2 years ago including ECG, echocardiogram, Holter monitoring and EEG which were all normal. He and his family were frustrated that no cause was previously found for his symptoms and did not attend follow up after his tests.
Examination
Physical examination is normal and postural blood pressures show no significant drop.
What would you do next?
There are no further investigations in primary care that would provide additional useful information. He requires further assessment from a dedicated syncope service.
Outcome
The syncope service organise tilt table testing and after 6 minutes of tilt he develops a sudden loss of consciousness with no response to verbal stimuli. Monitoring demonstrates no significant changes in heart rate, blood pressure, and no ECG changes. He is diagnosed with psychogenic pseudo-syncope (PPS) and was referred to a psychologist after full explanation to him and his family of what had happened.
Learning Points
- Tilt table testing can induce psychogenic syncope i.e apparent loss of consciousness without a change in recorded blood pressure and EEG. A slight tachycardia if 10-20 bpm is to be expected
- Diagnosis is based on the history and can be confirmed when a typical event is recorded during a tilt-table test with simultaneous BP, HR, EEG and video recordings of the patient
- Some factors can help distinguish PPS from vasovagal syncope
- Eyes are usually closed in psychogenic syncope but open in VVS
- Recurring multiple collapses in a single day suggest PPS.
Differentiating vasovagal syncope epilepsy and psychogenic pseudosyncope