Rubrics related to syncope in Kent and Boericke repertory

Dr. Shweta Singh

ABSTRACT
Syncope is transient self-limited loss of consciousness due to decreased Cerebral blood flow. It is followed by postural collapse and spontaneous recovery. Syncope may occur without any warning symptoms and the pathophysiology, approach, prognosis and treatment is determined by the underlying etiology. This article emphasis on the causes, investigation, management of the syncope along with its concerned rubrics from Kent and Boericke repertory.

KEYWORDS: SYNCOPE, VASOVAGAL, SITUATIONAL,VERTIGO

INTRODUCTION
The term Syncope refers to sudden loss of consciousness due to reduced cerebral perfusion ^[1]. Patient is nearly always in upright, sitting or standing position before syncope. The adequate blood pressure, sufficient oxygen supply and energy substrate like glucose is requires for normal functioning of the brain. Inadequacy of these elements due to hypotension, causes hypoxia or hypoglycaemia can lead to syncope.

Syncope takes the following course: –

PRESYNCOPE	SYNCOPE	POSTSYNCOPE
It refers which the Individual thinks light headedness in which the individual thinks may black out [1] This is the warning stage, Patient has: – Dizziness Swaying of floor Visual spots Ringing in the ear Nausea Vomiting Pale Face Perspiration	Patient losses consciousness for seconds to minutes. Patient is motionless  but sometimes feel few jerks of limbs.	When patient is in horizontal position retains consciousness. Bladder, bowel control is maintained.

EPIDEMIOLOGY
Syncope affects around 20%of the population at some time and accounts for more than 5% of hospital admission^[1] It has a prevalence of 42%, considering a life time of 70 years and an annual incidence of 6%^[2]. Its frequency varies from 15% (below 18 years of age) to 39% (among medical students) reaching 23% among the elderly. In the general population, the annual number episodes are 18.1–39.7 per 1000 patients, with similar incidence between genders, and with high prevalence between 10 and 30 years of age, mainly of vasovagal syncope.  

CAUSES OF SYNCOPE

1. VASOVAGAL SYNCOPE

• About 50% attacks of syncope are of this type. It is experienced by normal person. It is precipitated by -Hot and humid environment, overcrowded conditions, prolonged standing

-Extreme fatigue, severe pain

-Emotional and stressful situations

• Mostly patient experiences presyncope.
• In hot and humid condition there is loss of water and electrolytes, vasodilatation and venous pooling of blood. In these conditions forceful myocardial contraction with little blood is prevented by a vagal mechanism causing bradycardia and vasodilation leading to hypotension and syncope. Emotional factors cortical centers of emotion stimulate vagal mechanism causing hypotension and syncope.

2. POSTURAL HYPOTENSION

• Postural hypotension is transient and it is due to dysfunction of postural reflexes, which adjust BP during postural change. When BP is measured in lying down position and then in standing position a drop of 20mm in systolic BP and a drop of 10mm in diastolic BP indicates postural hypotension.
• It is more common in older people and mostly it occurs due to sudden rising from recumbent position.
• The common causes are –

-Drugs – Diuretics, alpha blockers. Vasodilators

-Hypovolemia- dehydration and blood loss.

-Peripheral neuropathy due to diabetes or alcohol or GBS (Guillain barre   syndrome).

– Due to physical deconditioning – after prolonged illness

3. CAROTID SINUS HYPERSENSITIVITY

• It is due to stimulation of hypersensitive baroreceptor situated at the bifurcation of carotid artery. It results in vagal overstimulation causing bradycardia and hypotension.
• It mostly affects men of >50 years of age and it is precipitated by shaving, wearing tight collar or tie or turning head backward without movement of the body.

4. SITUATIONAL SYNCOPE

The syncope is precipitated in some specific situations such as –

• Prolonged coughing in patients of asthma or COPD.
• Straining at micturition due to obstruction in urine outflow.
• Straining at defecation

-During cough, micturition and defecation intra thoracic and intra-abdominal pressure increases; it decreases venous return to the heart causing hypotension and syncope.

5. GLOSSOPHARYNGEAL NEURALGIA

Glossopharyngeal nerve dysfunction causes Pain in oropharynx and tongue. Impulse reaches the nucleus of IX nerve in medulla. This can stimulate nucleus of X nerve which causes bradycardia and vasodilatation leading to hypotension and syncope.

6. CARDIAC DISORDERS– The causes are –

Bradyarrhythmia’s – such as sick sinus syndrome or AV node block.

Tachyarrhythmias -such as supra ventricular tachycardia and atrial fibrillation.

• Ischemic heart disease such as MI.
• Pericardial effusion and constrictive pericarditis.
• Aortic stenosis -exertional syncope.

–  In tachyarrhythmias, high ventricular rate decreases ventricular filling. It decreases cardiac output causing hypotension.

– In constrictive pericarditis and pericardial effusion there is decreased ventricular filling.

Some old aged patients with diabetes present with painless extensive MI. These patients may present with dizziness and syncope.

7. CEREBROVASCULAR DISORDERS

-Such as vertebrobasilar insufficiency. It is due to atherosclerosis in vertebrobasilar arterial system.

It causes transient ischemia to the brain stem so patient presents with syncope.

INVESTIGATIONS-

Type of investigations are guided by history and physical examination.

1. Hb or haematocrit, Blood glucose, Serum electrolytes, Cardiac enzymes
2. 2.ECG-findout evidence of Myocardial Infraction, arrhythmias or heart block.
3. Holter monitoring for 24-48 hrs.
4. Echo-cardiography for valvular, pericardial or myocardial disease.
5. 5.Doppler ultra-sonography for carotid artery and vertebrobasilar artery insufficiency.
6. CT angiography for vertebrobasilar artery insufficiency.

MANAGEMENT

1.Treatment of underlying cause such as anaemia, hypovolemia, arrhythmia, urine outflow obstruction, constipation.

2.The patient who have suffered from syncope should be placed supine with head turned to one side or in lateral position to prevent aspiration. Some peripheral stimulation such as sprinkling of water will help to regain consciousness. Nothing should be given orally.

Fresh air should be allowed to come. When patient becomes conscious, he is not allowed to rise immediately because it may cause another attack of syncope.

3.Patients with carotid hypersensitivity should avoid situations which causes dizziness and syncope such as use of a tie. But if the disease is severe then pacemaker may be needed.

4.Patient with recurrent vasovagal syncope –

Should avoid the situation which causes syncope such as prolonged standing.

If patient cannot avoid the situation, then patient should load himself with water and salt.

5. Patient with history of postural hypotension

Elevation of head end of bed by 6-8 inches

The patient should rise slowly and systemically from supine to standing position, he should move his legs before rising from supine position then he should sit on the edge of the bed with dangling legs and should move the legs and then he should stand. This activity improves the venous return to the heart which prevents hypotension.

Patient should wear compression elastic stocking which helps in venous return.

The patient should avoid water and salt deficiency he should maintain water intake of 2-2.5 litre/day.

In these patients’ diuretics and vasodilators should be avoided.

6. Glossopharyngeal neuralgia should be treated.

7. For vertebrobasilar insufficiency atherosclerosis should be treated

REPRESENTATION OF SYNCOPE RELATED RUBRICS IN REPERTORIES

KENT REPERTORY^[3]

[VERTIGO] Syncope, with: Alum., ars., berb., bry.,canth., carb-v., cham., croc., glon., hep.,hipp., lach., mag-c., mosch., Nux-v.,paeon., phos., sabad., sulph.

BOERICKE’S REPERTORY^[4]

[FEMALE SEXUAL SYSTEM]

Complaints, Preceding And Attending Flow: Syncope: Ars.,Chin.,Ign.,Mosch.,Nux-m.,Nux-v.,Verat.

Pregnancy and Labor: Parturition,Labor: Pains: With Syncope: Cimic, Nux-v, Puls, Sec.

[CIRCULATORY SYSTEM]

Syncope, (fainting): Acetan., Acet-ac., Acon., Alet., Aml-ns., Apis, Ars.,Cact., Canth., Carb-v., Cham., Chin., Cimic., Coll., Croc., Cupr., Dig.,Ferr., Glon., Ign., Ip., Lach., Lil-t., Lina., Mag-m., Magn-gr., Mosch.,Nux-m., Nux-v., Op., Ph ac., Phase., Phos., Puls., Sep., Spig., Spong., Sulph., Sumb., Tab., Thyr., Tril-p., Verat., Zinc.

Syncope from odors, in morning, after eating: Nux-v.

Syncope, lipothymia, hysterical: Acon., Apisin., Asaf., Cham.,Cocc., Cupr.,Ign., Lach., Mosch., Nux-m.

[SKIN]

Urticaria (hives, nettle rash):Concomitants: Sudden, violent onset, syncope, with: Camph.

REFERENCES

1.Davidson’s Principles and Practice of Medicine; 24th Edition

2.Moya A., Sutton R., Ammirati F., Blanc J. J., Brignole M., Dahm J. B., et al.. (2009). Guidelines for the diagnosis and management of syncope. Eur. Heart J. 30, 2631–2671. 10.1093/eurheartj/ehp298 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

3. Kent.J.T : Repertory To the Homoeopathic Materia medica

4.Boericke OE. Boericke’s New Manual of Homoeopathic Materia Medica with Repertory. New Delhi: B. Jain Publisher, third revised & augmented edition, 2008.

Dr. Shweta Singh
Department Of Repertory,
Bakson Homeopathic Medical College And Hospital,Greater Noida,Uttar Pradesh,India