← Diagnosis and Management Guides
Syncope Evaluation
Key considerations: Seizure mimicking syncope, Cardiac arrhythmia causing syncope, Vertebrobasilar TIA
Cannot miss
- Seizure mimicking syncope
- Cardiac arrhythmia causing syncope
- Vertebrobasilar TIA
- Subclavian steal syndrome
Likely diagnoses
- Vasovagal syncope
- Orthostatic hypotension
- Cardiac arrhythmia
- Situational syncope
- Carotid sinus hypersensitivity
Red flags
- Syncope during exertion (cardiac cause)
- Syncope with chest pain
- Syncope in supine position (not vasovagal)
- No prodrome
- Family history of sudden cardiac death
- Focal neurologic findings post-event
- Age >60 with first syncope
Workup
- history: Prodrome, position, activity at onset, witnesses, post-event confusion duration, medications, family history; exam: Orthostatic vital signs, cardiac auscultation (murmurs), carotid bruits, neurologic exam; labs: ECG (mandatory in all), glucose, CBC, BMP, troponin if cardiac concern; imaging: Head CT only if focal findings or head trauma; Echocardiogram if structural heart disease suspected; bedside: Orthostatic vitals, ECG, cardiac monitoring
Management
- immediate: Treat underlying cause if identified; general: Vasovagal: education, avoid triggers, increase salt/fluid, compression stockings, fludrocortisone if refractory; Orthostatic: volume repletion, medication review, compression garments, midodrine; Cardiac: cardiology referral, pacemaker or ICD as indicated; Tilt-table test for recurrent unexplained syncope
Disposition
- admit: High-risk features per Canadian Syncope Risk Score, abnormal ECG, cardiac syncope suspected; discharge: Low risk with clear vasovagal etiology and outpatient follow-up; consults: Cardiology if cardiac cause suspected, neurology if seizure suspected
Clinical pearls
- Tongue biting (lateral tongue, not tip), prolonged post-ictal confusion (>5 min), and witnessed tonic-clonic activity point toward seizure rather than syncope
- Brief myoclonic jerks CAN occur with syncope — do not mistake for epileptic seizures
- Canadian Syncope Risk Score effectively risk-stratifies ED syncope patients
Source and review
- ESC Syncope Guidelines 2018. Last reviewed: 2024-11-01