PRE-SYNCOPE/SYNCOPE

• Most causes can be identified by a thorough clinical assessment
• Assessment should follow a detailed account of the preceding/premonitory symptoms, witnessed observations and succeeding complaints
• Recorded vital signs by health providers at the scene provide valuable clues 
• Drugs are a contributing cause to recurrent falls/syncopal episodes
• If few symptoms are present you must consider arrhythmias, unrecognised GI bleeding and pulmonary embolism

HISTORY

The logical approach is a detailed chronology of the event:

• Warning, Premonitory symptoms, Last recollection of patient prior to collapse
• Witnessed accounts during the episode
• Ambulance report - especially initial vital signs and ECG rhythm
• Immediate recollections upon recovery

EXAMINATION

Should focus on:

• Vital signs and detailed cardiovascular and neurological examination
• Search for sources of infection
• Occult blood loss
• Evaluate injuries

See Important feature to note

See Important causes of syncope

INVESTIGATIONS

• BSL
• ECG (most important - see ECG and the Collapsed Patient)
• MSU

As indicated:

• FBC
• EUC
• ABG
• CXR

DISPOSAL

Discharge after observation for 4 hours if:

• No serious cause identified
• LOC < 1 min
• Vital signs/Examination normal
• ECG normal
• Previous normal Holter monitor or electrophysiological studies (EPS)

Admit if:

• Serious cause found
• Prolonged LOC

Admit with continuous ECG monitoring (telemetry) for 48 hours if:

• No alternative cause found

WITH any of the following:

• Associated cardiac symptoms - chest pain, palpitations
• Multiple risk factors for cardiac disease
• Strongly suggestive ECG abnormalities (see ECG and the Collapsed Patient)

PROGNOSIS

Patients who have been previously thoroughly evaluated for recurrent syncope including Holter monitoring or EPS studies have no increase in long term mortality compared to controls.