Common problem in Emergency Medicine, often initially labelled as "collapse ?cause."
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.
Severe orthostatic hypotension
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.
|Disposition||Driving restrictions as per UK DVLA guidelines **|
|1. Simple Faint
Definite provocational factors with associated prodromal symptoms and which are unlikely to occur whilst sitting or lying. Benign in nature. If recurrent, will need to check the 3 "Ps" apply on each occasion (provocation / prodrome / postural).
|Discharge, if social circumstances favourable||
No driving restrictions
No driving restrictions
|2. Loss of consciousness / loss or altered awareness likely to be unexplained
syncope . low risk of re-occurrence.
These patients have no relevant abnormality on CVS and neurological examination, and have a normal ECG.
|Refer to GP for follow-up. However, if you feel investigations are warranted refer the patient to Syncope Clinic. See referral form in ED||
Can drive 4 weeks after event.
Can drive 3 months after event
|3. Loss of consciousness / loss or altered awareness likely to be unexplained
syncope . high risk of re-occurrence
Factors indicating high risk:
associated chest pain
clinical evidence of structural heart disease ( be particularly aware of aortic stenosis )
sudden syncope occurring whilst driving, or whilst sitting / lying, or on exertion.
more than one episode in previous six months.
Admit overnight to the obs unit or under the medical team
Arrange review by the Cardiology team on their post take ward round
Can drive 4 weeks after the event if the cause has been identified and treated.
If no cause identified, then require 6 months off.
Can drive after 3 months if cause has been identified and treated.
If no cause found then licence refused/revoked for one year.
|4. Unwitnessed (presumed) loss of consciousness / loss or altered awareness
with seizure markers
The category is for those where there is a strong clinical suspicion of epilepsy but no definite evidence.
The seizure markers act as indicators and are not absolutes
|Admit medically if suspect new-onset epilepsy, or focal neurology
present. The latter group will need urgent neuroimaging ( see the CT
If relapse in known epileptic then admission not always indicated, provided the seizure activity represents their normal pattern
I year refusal/revocation
5 year refusal/revocation
**Group I; cars, motorcycles, Group II; LGV, HGV etc.
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.
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.
DVLA site - await link
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 30/08/12