What is the immediate management for Stokes-Adams attacks?

Stokes-Adams Attacks: Summary and Management

Stokes-Adams attacks are medical emergencies requiring immediate intervention with temporary or permanent cardiac pacing as the definitive treatment for most cases, particularly those caused by high-degree AV block or asystole.

Definition and Pathophysiology

Stokes-Adams attacks are characterized by sudden, transient loss of consciousness due to cerebral hypoperfusion caused by a sudden decrease in cardiac output. These episodes typically result from:

• High-degree or complete atrioventricular (AV) block (50-60% of cases) 1
• Sinoatrial (SA) block (30-40% of cases) 1
• Paroxysmal tachycardia or fibrillation (0-5% of cases) 1

The hallmark feature is abrupt onset of syncope with spontaneous recovery, often accompanied by seizure-like activity due to cerebral hypoxia.

Clinical Presentation

• Sudden loss of consciousness with spontaneous recovery
• Possible seizure-like activity during the attack
• May be preceded by prodromal symptoms (lightheadedness, visual changes)
• Often recurrent episodes
• Patients typically have abnormal ECGs between attacks (widened QRS, bundle branch block, or AV block) 1

Immediate Management

1. For Witnessed Attack in Progress:

• Establish airway, breathing, circulation
• Position patient supine with legs elevated
• Monitor vital signs and ECG continuously
• For asystole or severe bradycardia:
  • Atropine 3 mg IV bolus for bradycardia 2
  • If available, initiate temporary transcutaneous pacing immediately 2
  • If transcutaneous pacing unavailable, consider low-dose adrenaline infusion 2

2. For Intrinsic AV Block (Stokes-Adams Attack):

• Immediate cardiac pacing is indicated 2
• If the patient is in a monitored setting and conscious, cough CPR may be considered as a temporary measure while preparing for definitive treatment 2
• For witnessed monitored arrest with ventricular tachyarrhythmias, precordial thump may be considered, though defibrillation is preferred if immediately available 2

Post-Attack Management

Diagnostic Evaluation:

• Continuous ECG monitoring to capture the arrhythmia responsible
• If diagnosis uncertain, consider:
  • Holter monitoring (for suspected sick sinus syndrome) 1
  • Electrophysiologic studies including His bundle electrography 1

Definitive Treatment:

• Permanent pacemaker implantation is the definitive treatment for most cases 3, 1, 4
• For AV block causing Stokes-Adams attacks, permanent pacing is indicated with Class I recommendation 2
• Dual-chamber pacing is preferred over single-chamber ventricular pacing to maintain AV synchrony and reduce risk of pacemaker syndrome 2, 1
• For patients with tachycardia/bradycardia syndrome, additional anti-arrhythmic treatment may be required 1

Special Considerations

• Medical therapy alone (isoproterenol, ephedrine, atropine, steroids) is generally ineffective for long-term management 3, 1
• Patients with Stokes-Adams attacks due to AV block are at high risk for sudden death if left untreated 4
• Even elderly patients (up to 88 years of age) have shown excellent response to pacemaker therapy with elimination of Stokes-Adams attacks 3
• In rare cases of Stokes-Adams attacks due to acute rheumatic fever, temporary pacing may be sufficient until the inflammatory process resolves 5

Prognosis

With appropriate pacemaker therapy, prognosis is excellent with:

• Complete resolution of Stokes-Adams attacks in most patients 3, 6
• Significant improvement in physical activity and quality of life 6
• Long-term survival dependent on underlying cardiac disease rather than the conduction disorder itself

Follow-up

• Regular pacemaker checks to ensure proper functioning
• ECG monitoring to detect any changes in underlying rhythm
• Evaluation for progression of underlying cardiac disease

Stokes-Adams attacks represent a potentially life-threatening condition that requires prompt recognition and definitive treatment with cardiac pacing to prevent recurrence and sudden death.