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