Decision
Do history, physical, or ECG suggest an etiology?
Yes
Does the presentation favor neurally mediated or orthostatic syncope?
- If so, manage as outpatient (Class II).
- If an alternate etiology is favored, consider structured evaluation in syncope unit versus observation (Class II)
No
Risk-stratify patients using clinical findings and consider using risk-stratification scores (Class II)
- “Risk-stratification tools should be applied only to patients for whom no apparent cause of syncope has been determined after the history, physical examination, and ECG have been performed. Overall, risk-stratification tools do not appear to perform better than unstructured clinical judgment in predicting adverse events, and their application does not appear to reduce admission rates.” (1)
- The following scoring methods are available at MD Calc.
Background
Historical Features Suggesting Etiology of Syncope
- Neurally Mediated Syncope
- Long history of syncope, especially if beginning before age 40
- Triggered by pain, medical procedure, environmental stimuli (sight, sound, smell)
- Occurs after prolonged standing
- Prodrome of nausea, sweating, pallor, or flushing: "tunnel vision"
- Associated with crowds or hot places
- After exercise or exertion
- During a meal
- During or after micturition, coughing, swallowing, or defecation
- Associated with head-turning or pressure on carotid sinus (shaving, tight collars)
- Orthostatic Hypotension-Mediated Syncope
- Shortly after standing
- Prolonged standing or standing after exertion
- Postprandial hypotension
- Associated with initiation or increased dose of certain medications
- History of autonomic neuropathy
- Cardiac Syncope
- During exertion or while supine
- Palpitations preceding syncope or no prodrome
- Family history of sudden cardiac death at a young age
- Known structural heart disease or coronary artery disease
Electrocardiogram Findings Associated With Serious Cardiac Arrhythmias Within 30 Days
- Non-sinus rhythm
- Multiple premature ventricular contractions
- Short PR interval
- First-degree atrioventricular block
- Complete left bundle branch block
- Findings consistent with acute or chronic ischemia (Q waves T-wave/ST-segment changes)
A table listing of all available Syncope Risk scoring methods appeared in the article. (1)
References
- Morris J. Emergency department management of syncope. Emerg Med Pract. 2021 Jun;23(6):1-24. Epub 2021 Jun 1. PMID: 34008935.
