Circumstances prior to the episode (position, activity, predisposing factors or precipitating events).
Symptoms at onset of episode (nausea, aura, visual, cardiac symptoms etc.).
Details of the episode (you will need a witness, or collateral history from the ambulance crew): skin colour, duration of loss of consciousness, breathing pattern, movements, tongue biting etc.
End of the episode: confusion, muscle aches, colour, injury, incontinence.
Previous presyncopal or syncopal episodes, previous cardiac and medical history, family history (sudden cardiac death, epilepsy etc.
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.
Check for injury.
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 (ideally 12 lead but rhythm strip also very useful).
Blood tests are useful only if clinically indicated.
You should do a blood glucose.
Consider a pregnancy test in women of childbearing age.
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.
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. The patient should fit into one of the categories in the
disposal grid below. 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.
If you have identified an underlying cause, disposition should be guided by the
disposal grid below.
If the patient is not admitted they should either be referred back to GP, or they can be referred directly toa neurology clinic. The latter option is best for patients in Group 2 below, or those with recurrent symptoms.
Fitness to drive
More information s available from the RSA website and their 2013 Fitness to Drive guideline (local copy).
Below is a selection of some of the recommendations relating to syncopy. For more details, please se the RSA site / above document.
Fitness to Drive - Syncope - summary
Group 1 (car/motorcycle)
Reflex vasovagal syncope
If recurrent check the "3Ps" (pprovocation/prodrome/postural)
LOC /altered awareness likely to be unexplained syncope but with a high probability of reflex vasovagal syncope. No evidence of structural heart disease and normal ECG
**Group I; cars, motorcycles
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 disorders (hypoglycaemia, hypoxia)
TIAs of vertebrobasilar origin
Disorders resembling syncope without LOC
Drop attacks (although these can be syncopal in origin. If they are recurrent consider referral to syncope clinic)
Pseudosyncope, 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.
Presyncope should be evaluated as being an identical entity to true syncope
Syncope / neurology clinic
To refer a patient write a standard referral letter, preferably typed by the ED secretaries. Include information such as the circumstances of the episode, and ED assessment. A copy of the patient's ECG and any rhythm strips should be enclosed. If relevant request a 24 hour ECG tape prior to the appointment.
European Task Force report; Guidelines on management of Syncope. Brignole et al. European Heart Journal 2001; 22: 1256-1306.
'At a glance' Guide to the current medical standards for fitness to drive.Drivers medical group, DVLA, Swansea. Jan 2003.
Risk stratification of patients with syncope in an accident and emergency department.
Crane S. EMJ 19(1): 23-7.
Potential drug-drug interactions in elderly patients presenting with syncope.Gaeta et al. J Emerg Med '02; 159-62.
Strategy for the management of vasovagal syncope. Bloomfield et al. Drugs Aging 2002; 19(3): 179-202.
Diagnosing syncope in clinical practice. Implementation of a simplified diagnostic algorithm in a multicentre prospective trial- the Oesil trial.
Ammirati et al. European Heart Journal 2000; 21: 935-40.
Diagnosing syncope Part I; Clinical guidelines. American College of Physicians. Linzer et al. Ann Intern Med 1997; 126(12): 989-96.
Diagnosing syncope Part II; Clinical guidelines. American College of Physicians. Linzer et al. Ann Intern Med 1997; 127(1): 76-86.
Content Dr Ian Higginson 10/06/2003. Reviewed by Dr Íomhar O' Sullivan 08/03/2004, 16/05/2005. Reviewed by Dr Chris Luke 05/11/2005, Dr . ÍOS 28/05/2009. Last review DR. ÍOS 23/04/14