Mount Carmel Health Partners Clinical Guidelines Syncope

Syncope Clinical Guideline Definition: Syncope is the term used to describe a temporary loss of consciousness (LOC) due to the sudden decline of blood flow to the brain. Often referred to as fainting or “passing out,” syncope is most often a transient and benign condition, and the event will have no long-term significance. In some cases, syncope is a sign that a dangerous or even life-threatening underlying medical condition may be present. LOC associated with increased muscle tone is a neurologic (or sometimes psychiatric) event, not a cardiac one. Determine if the event is “true” syncope: transient LOC with loss of muscle tone and followed by a return to baseline neurologic function. Perform focused history and physical exam; focus on vital signs, cardiovascular, and neurologic systems: • prodrome? • exertional or post-exertional? • while lying, sitting vs. standing? • taking meds that increase QT interval? Evaluation Treatment PMHx: Family History: • CAD/CHF? • sudden cardiac death? • ventricular arrhythmia? • history of epilepsy/migraines headaches? Evaluate with ECG and orthostatic BP (see Table One) • Evaluate Sp0₂ • Obtain focused lab, e.g., CBC (hgb), BMP, BNP • Apply ROSE clinical decision rule (see box on right) Event is true syncope Yes R—Rectal exam, positive for fecal occult blood A—Anemia (Hgb <9 g/dl) C—Chest pain associated with syncope E—ECG, Q wave (not lead III) S—SpO₂ <94% on room air Potentially serious cause? Unexplained syncope CVA/Stroke Pre-syncope Lightheadedness Unresponsiveness Seizure Trauma No Order echocardiogram Consult specialty service as appropriate (see Table Two) B—BNP >300 Bradycardia <50 bpm Event may not be true syncope Syncope with clear cause Hospitalize to observation or inpatient with telemetry monitor ROSE Clinical Decision Rule (BRACES) Patients with one or more should be considered for admission. Non-life threatening causes of syncope that typically do not require hospitalization: • Neurocardiogenic/vasovagal • Vasomotor syncope • Situational syncope • Medication-related • Orthostatic hypotension • Hypoglycemia or toxins Risk stratification High Low Admission for evaluation and cardiac monitoring: • Significantly abnormal ECG in appropriate for clinical setting Admission evaluation and cardiac • monitoring: Sustained v fib and v tach • • Hematocrit less than 30 ECG in appropriate Significantly abnormal • Shortness of breath clinical setting • • SBP less than 90 and mmHg Sustained v fib v tach • • Recurrent acute Hematocrit less seizures than 30 difficult to • control Shortness of breath • • Family history SBP less than of 90 sudden mmHg cardiac before acute age 40-50 • death Recurrent seizures difficult to • Advanced control age (80 or frail appearing) • Family history of sudden cardiac death before age 40-50 • Advanced age (70 or frail appearing) Low-risk: ECG normal and patient asymptomatic with explainable cause Discharge or close interval follow-up with PCP or cardiologist in 1-2 weeks November 2017