Patients who present to the emergency department following a syncopal episode can be a diagnostic challenge to us. There are 5 things we should always do, to help us make the diagnosis.

Before we start with the big 5, I need to make 3 general comments:

1. Syncope is a symptom, not a condition. We need to find the underlying condition causing it.
2. Syncope and Pre-Syncope should be grouped together to minimise misses.
3. We need to have a standardised definition of Syncope.

Definition of Syncope

There are 3 parts to the definition:

• Sudden brief loss of consciousness
  • The key here is that the duration of syncope is short
  • The suddenness of the episode may give us a clue as to the cause. If no prodrome, consider a cardiac cause.
• Loss of postural tone
  • The patient who is standing will collapse
• Spontaneous recovery to baseline
  • The recovery occurs spontaneously and rapidly
    • In younger patients vasovagal causes of syncope should resolve in about 30 seconds
    • In older patients it may take one or two minutes to baseline
    • If the time to reach baseline takes more than 5 minutes, as a general rule, consider seizure as the diagnosis.
  • The patient must return to their baseline conscious state and functioning level

5 Things You MUST DO?

When trying to make a diagnosis in the patient presenting with syncope, we need to be flexible with our approach and target the high yield areas first. We can ask about medications and allergies etc., and these are important, but what is more important is to determine:

• Was this a faint or a fit?….and
• If syncope, was it cardiac or not?

In fact if we concentrate on cardiac or not, we will get most of the high mortality/morbidity causes out of the way.

1. 5 things specific in the history

1. What Happenned just before the episode? Was there a PRODROME?
   1. Sudden collapse with no prodrome is suspicious of an arrhythmia.
   2. Identifying cardiac causes is very important as they are associated with greater morbidity and mortality.
2. What Happenned DURING the event? Was there a seizure?
   1. Beware the collateral history of a seizure, as myoclonic jerking movements, associated with hypoxia may be mistaken a seizure. The key is the presence of post ictal to differentiating may be the presence of a post-octal period.
3. What happenned right after? Back to normal or decreased conscious state
   1. How quickly did the patient return to a normal conscious state?
   2. If it takes > 5 minutes to return to a normal state, think of a seizure
4. Any previous episodes?
   1. Find out the circumstances. Was it related to exertion or noxious stimuli etc.?
5. Family History of syncope or sudden cardiac Death?
   1. Always pursue the family history to uncover and potential congenital disorders including Brugada Syndrome.

2. Ask about 5 ‘Syncope PLUS’ 

Asking about the symptoms that may have accompanied the episode of syncope can give us clues to the cause.

1. Syncope PLUS Headache
   1. This can help identify an intracranial bleed. Syncope can be associated with large bleeds, but also with small subarachnoid ‘sentinel’ bleeds.
2. Syncope PLUS Chest Pain
   1. Is this cardiac ischaemia? Or if the chest pain was sudden and severe, or perhaps tearing, is it a dissection?
3. Syncope PLUS Palpitations
   1. Could this have been an arrhythmia?
4. Syncope PLUS SOB
   1. Could a cause of SOB such as a pulmonary embolism have caused this?
5. Syncope PLUS Abdominal pain
   1. Could this be a GIT bleed or a AAA?

The syncope PLUS approach is imperative to capturing some of those high risk presentations.

3. 5 things to look for in the ECG

1. Ischaemia
2. Blocks including, Mobitz, Fascicular and BRUGADA
3. Cardiomyopathy
4. Abnormal intervals: Short PR(WPW), Long/Short QT
5. Evidence of PE: Right heart strain, T wave inversion ant/inf

The ECGs of syncope can be found here briefly. For a detailed coverage go to the cardiac bootcamp Course section on syncope. There are particular predictors of arrhythmias that can be found in the ECGs of the elderly. 

4. 5 specifics in the Examination

1. Cardiac: Murmurs of MI or AS
   1. These might indicate several potential diagnoses including:
      1. Outflow tract from calcified valves
      2. Outflow tract obstruction murmur from hypertrophic cardiomyopathy
2. Abdo: Pulsatile mass
   1. Is this a AAA?
3. PR Exam: Bleeding
   1. GIT bleeding can be painless. The bleed can cause syncope, not due to significant loss of blood but due to response to the bleed.
4. Neurological: Any deficit
   1. Any deficits may indicate a neurological cause causing seizure.
   2. Thinks of Todds paresis
5. Tongue: Tongue bitting
   1. It’s true that patients with both seizures and syncope can bite their tongue.
   2. Patients with seizures tend to bite the tip of their tongue and those with syncope the lateral edge of their tongue, although this may not always be the case.
   3. Tongue bitting should be considered to be caused by seizure, until proven otherwise.

5. 5 HIGH RISK Factors

The high risk group is the group that usually requires admission. There are 5 things to consider. I’ve written about syncope rules before. These capture the higher risk patients, however we should take care about how we use these rules. I use them when I’m about to discharge someone as a last check list.

My 5 predictors for high risk patients are:

1. Older patients, usually > 65yo
2. Syncope with NO Prodrome
3. Cardiac History including arrhythmias, CCF, structural heart disease
4. Abnormal ECG
   1. What is abnormal? Anything that’s not normal.
5. Syncope PLUS Criteria

High risk patients usually need admission.

I hope these 5 rules help in your approach to the patient with syncope. Remember that these are targeted areas and I consider them a bare minimum in your approach to these patients.

Download the infographic to assist in remembering:
5-Steps For Every patient with Syncope-3

Let me know if you have any other helpful hints.