EMed

Syncope

Background

This is common symptom in Emergency Medicine, often initially labelled as "collapse ?cause."

Definition of Syncope

  • Transient self-limited loss of consciousness
  • The onset is usually rapid and the recovery is spontaneous, complete and usually (but not always) prompt

Patients who are still unconscious when they are brought into the ED have not had a syncopal episode since their recovery doesn't fit the criteria. They should be evaluated for coma.

EM assessment of syncopal patients

  1. Full diagnostic assessment
  2. Risk stratification (CSRS) and appropriate disposition. Note that patients with syncope of a cardiac origin are at risk of sudden death and must be assessed in detail
  3. Exclusion of significant injury
  4. Consideration the patient's occupation and driving status to guide immediate discharge advice

Principal causes of syncope

Cardiac syncope

  • Arrhythmias
  • Structural including:
    • Valvular heart disease
    • LV outflow (NB aortic stenosis)
    • Cardiac tamponade
    • PE

Reflex-mediated

  • Simple faint
  • Situational syncope: micturition, cough, defecation, pain, swallowing
  • Carotid sinus syndrome

Orthostatic hypotension

Epilepsy

Assessment (risk)

Hx Hx Hx

  • Circumstances prior to the episode (position, activity, predisposing factors or precipitating events)
  • Symptoms at onset of episode (nausea, aura, visual, cardiac symptoms)
  • Details of the episode (you will need a witness, or collateral history from the ambulance crew): skin colour, duration of LoC, breathing pattern, movements, tongue biting
  • In general:
    • <10 "twitches" = syncope
    • >20 "twitches" = seizure
  • End of the episode: confusion, muscle aches, colour, injury, incontinence
  • Previous pre-syncopal or syncopal episodes, previous cardiac and medical history, family history (sudden cardiac death, epilepsy etc
  • Medications
  • Occupation and driving status

Physical examination and investigations

  • Focus particularly on the cardiovascular and neurological systems
  • Note the resting heart rate, BP, and SpO2 on air
  • Listen for aortic stenosis
  • Check for injury
  • Walk the patient and observe gait / steadiness
  • Diagnostic carotid sinus massage should only be performed by an experienced operator, who is familiar with both the contraindications and interpretation of any effect
  • 12 lead ECG in all patients. Look for arrhythmias and conduction defects (i.e. AV block, BBB, prolonged QTc etc ). If patient has symptoms whilst in the department obtain a contemporaneous ECG
  • Blood tests (bar TnI) only if clinically indicated
  • You should do a blood glucose
  • Consider a pregnancy test in women of childbearing age
  • Please note a CT brain is not routinely required

Orthostatic hypotension (OH) is an unusual primary cause of syncope. It might be worth looking for in patients who have syncope immediately related to assuming an upright posture. Because the test (using standard BP equipment) has a low sensitivity in detecting OH, it is important to document whether symptoms occur in the absence of BP change.

Canadian Syncope Risk Score (CSRS)

CSRS is used to evaluate the risk of adverse outcomes in patient who present with fainting or syncope.

CSRS

Condition

Points

Predisposition to vasovagal symptoms *

 -1

Hx heart disease †

 1

Any SBP <90 or >180 mmHg ‡

 2

↑ TnI

 2

Abnormal QRS axis (<-30° or >100°)

 1

QRS duration > 130 ms

 1

QTc interval >480 ms

 2

Clinical vasovagal syncope

 -2

Clinical cardiac syncope

 2

Total score

 (-3 to 11)

* Triggered by being in a warm room, fright etc.
† Incl. valvular Hx, CAD, cardiomyopathy, CCF, Hx non-sinus rhythm
‡ Incl. all BP values while in the ED

Risk serious outcome (@30 days)

Total score

Risk adverse event

Risk category

Disposition CUH

-3 to -2

 0.4% - 0.7% Very low Discharge

-1 to 0

 1.2% - 1.9% Low Discharge ± GP

1 to 3

 3.1% - 8.1% Medium Refer medical

4 to 5

 13% - 20% High Refer medical

6+

 29% - 84% Very high Admit cardiol.

Other ECG abnormalities include:

  1. Aortic stenosis
  2. Brugada (saddle STE V1-V3)
  3. Corrected QT (LQTS beware >500ms)
  4. Delta wave (WPW)
  5. Epsilon wave of ARVD
  6. Fluid (alternans, low voltage of pericardial fluid)
  7. Giant PE (RAD, RBBB, TV1 - V3, S1Q3T3)
  8. Hypertrophy where not expected (HOCM)
  9. Intervals - (PR , 2nd/3rd degree block, BBB)
  10. Ischaemia

A patient with any of the above measures is considered at high risk (death, AMI, arrhythmia, PE, stroke, SAH, haemorrhage).

ECG check

Measuring lying and standing BP

Identify if you are going to need assistance to stand the patient and simultaneously record a BP. Use a manual sphygmomanometer if possible and definitely if the automatic machine fails to record.

  1. Explain procedure to the patient
  2. The first BP should be taken after lying for at least five minutes
  3. The second BP should be taken after standing in the first minute
  4. A third BP should be taken after standing for three minutes
  5. This recording can be repeated if the BP is still falling
  6. Symptoms of dizziness, light-headedness, vagueness, pallor, visual disturbance, feelings of weakness and palpitations should be documented
  7. A positive result is:
    1. ↓ in SBP of ≥20mmHg (± symptoms)
    2. ↓ <90mmHg on standing even if the drop is less than 20mmHg. (with or without symptoms)
    3. ↓ DBP of 10mmHg with symptoms (although clinically less significant than a drop in systolic BP)
  8. Advise patient of results and if the result is positive,
    1. inform the medical and nursing team
    2. take immediate actions to prevent falls and or unsteadiness
  9. In the instance of positive results, repeat regularly until resolved
  10. If symptoms change, repeat the test

NICE Clinical Guideline 161 Falls in older people: assessing risk and prevention says that the following groups of inpatients should be regarded as being at risk of falling in hospital and should receive an individualised, multi-factorial assessment: all patients aged 65 and patients aged 50 to 64 years who are judged by a clinician to be at higher risk of falling because of an underlying condition.

Management

The majority of patients with syncope will have normal findings on examination and be fully recovered when assessed. However risk stratification, particularly seeking cardiac causes, is crucial to disposition. If in doubt, please seek advice.

Patients may warrant referral to a Syncope Clinic for diagnostic work-up (EEG, CT, tilt test etc.). Even if you suspect the patient is suffering from simple faints remember there are other proven interventions for those with recurrent vasovagal syncope.

The incidence of 'simple faints' can be reduced (without referral to a clinic) by advising the patient about avoidance of precipitating situations, maintaining hydration, not getting overheated, and taking avoiding action if warning symptoms appear. Many patients do not realise that lying down can be effective if they feel dizzy.

Adjusting cardiovascular medications may be helpful, especially in elderly patients who are having giddy spells with postural change and occasional syncope. By reducing the dose of a cardioinhibitory medication, or omitting a vasodilator (depending on whether you think they have symptomatic bradycardia or resting hypotension ), symptom frequency can be reduced. Advise both the patient and GP of any adjustments. If reducing a diuretic or antianginal ensure the patient/carer understands that breathlessness or angina are indications for restarting their 'culprit' medications, and to see their GP.

Fitness to drive

More information is available on our "driving" page.

For patients requesting a formal assessment specifically checking for driving ability, Mr. Sean O' Callaghan (Southern Mobility Assessments 087 9304335) is available for an initial fee of circa €100.

Conditions that can easily be mislabelled as syncope

Disorders with impairment or loss of consciousness

  • Metabolic (hypoglycaemia, hypoxia)
  • Intoxication
  • TIAs (vertebrobasilar)

Disorders resembling syncope without LOC

  • Cataplexy
  • Drop attacks (although these can be syncopal in origin. If they are recurrent consider referral to syncope clinic)
  • Pseudo-syncope, somatisation disorders
  • TIAs of carotid origin

Points to note

  • Brief symptoms / signs such as nausea, and diaphoresis are common and non-specific in syncope
  • Brief myoclonic jerking is common in syncope. Syncope may also present as a true seizure, due to the cerebral hypoperfusion
  • Pre-syncope should be evaluated as being an identical entity to true syncope

Suggestive of epilepsy

  • A bitten tongue (laterally)
  • Head-turning to 1 side during TLoC
  • No memory of abnormal behaviour that was witnessed before, during or after TLoC by someone else
  • Unusual posturing
  • Prolonged limb-jerking (note that brief seizure-like activity can occur during an uncomplicated faint and is not necessarily diagnostic of epilepsy)
  • Confusion after the event
  • Prodromal déjà vu or jamais vu

Seizure less likely

  • Prodromal symptoms that on other occasions have been abolished by sitting or lying down
  • Sweating before the episode
  • Prolonged standing that appeared to precipitate TLoC
  • Pallor during the episode

Neurology clinic (if epilepsy suspected)

Last review Dr ÍOS 18/02/24