SYNCOPE/PRESYNCOPE
PRACTICE GUIDE
When using any Practice Guide, always follow the Guidelines of Proper Use
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Definitions
● Transient loss of consciousness or near loss of
consciousness secondary to decreased perfusion of
brain
Differential Diagnosis
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Cardiac arrhythmia
Pulmonary embolism
TIA
CVA
Seizures
Dehydration
Aortic stenosis
Hypoglycemia
Subarachnoid hemorrhage
Hemorrhage
● GI bleeding
● Ectopic pregnancy
● Adrenal insufficiency
● Sepsis
Causes
● Neurally mediated
● Vasovagal
● Situational
● Carotid sinus
● Psychiatric
● Orthostatic
● Volume depletion or hemorrhage
● Advanced age
● Medications
● Neurologic
● Cardiac
● Unknown
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Considerations
● EKG recommended in all patients
● Testing for unexplained syncope is based on risk
factors
● Vasovagal episode is the most common cause
● Medication can cause syncope or presyncope
Clinical important features suggestive of specific
cause
Exertion
• Aortic stenosis
• Mitral stenosis
• Coronary artery disease
Head rotation
• Carotid-sinus syncope
Arm exercise
• Subclavian steal
Red Flags
● Exertional onset: ischemic coronary disease or aortic
stenosis
● Chest pain: ischemic coronary disease
● Severe headache: subarachnoid or cerebral
hemorrhage
● Low back pain: aortic dissection or aneurysm
● Dyspnea: pulmonary embolism or CHF
● Palpitations: symptomatic arrhythmia
● Neurologic deficits
Evaluation
● Syncope/presyncope lasting < 20 seconds in healthy
patients get an EKG, but may not need further testing
if all the following exist:
● Age < 50
● Normal physical exam
● Normal vital signs and O2 sat on room air
● No comorbidities
● Clinically had a vasovagal episode
● No other complaints
● Perform orthostatic vital signs
● Blood pressure measurements in both arms for
comparison
● Apply Well’s pulmonary embolism and DVT criteria and
chart Well’s score as indicated
● Record positive or negative calf tenderness and
Homan’s sign
All other patients order options
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CBC
BMP
Chest x-ray
EKG
UCG if pregnancy possible
Check stool hemoccult if any of the following
• Acutely anemic
• Tachycardic
• Orthostatic vital signs
• Melena or rectal bleeding history
● Chest pain: order troponin (angina) and D-dimer
● Consider CT head for neurologic complaints,
findings or headache (low yield otherwise)
Evaluation with D-dimer
D-dimer (LIA method) — some methods currently
in use not reliable
 Useful if negative at cutoff value to rule
out DVT or PE
 Negative D-dimer with low to moderate
probability Well’s DVT score largely
excludes venous thromboembolic disease
 Well’s DVT criteria high probability: order
ultrasound scan regardless of D-dimer
result
 If positive — not as useful as a negative
result which usually rules out VTE (venous
thromboembolic) disease
 Frequently positive with
 Hospitalization in past month
 Chronic bedridden or low activity
state
 Increasingly positive with age without
significant acute disease process
 CHF
 Chronic disease processes
 Edematous states
Well’s DVT criteria
• One point each:
 Active cancer
 Paralysis/recent cast immobilization
 Recently bedridden > 3 days or surgery <
4 weeks
 Deep vein tenderness
 Entire leg edema
 Calf swelling > 3 cm over other leg
 Pitting edema > other calf
 Collateral superficial veins
• Two points — alternative diagnosis less likely
High probability: ≥ 3 points
Moderate probability: 1–2 points
Low probability: 0 points
Well’s PE criteria score 3 or greater consider
D-dimer and CT chest PE Protocol
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Suspected DVT = 3
Alternative diagnosis less likely than PE = 3
Heart rate > 100 = 1.5
Immobilization/surgery past 4 wks = 1.5
Previous DVT/PE = 1.5
Hemoptysis = 1
Cancer past 6 months = 1
Well’s score ≥ 6: order CTA chest PE Protocol
(recommend physician consultation)
Document positive or negative Homan’s sign or calf
tenderness regardless of Well’s scores
Document PERC and/or Well’s scores when appropriate
Pulmonary Embolism Rule-out Criteria (PERC Rule)
(Reportedly decreases significantly the likelihood of
pulmonary embolism if all 8 criteria met)
• Age < 50
• Pulse oximetry > 94%
• Heart rate < 100
• No history of DVT or VTE
• No hemoptysis
• No estrogen use
• No unilateral leg swelling
• No recent surgery or trauma hospitalization
past 4 weeks
Treatment Options
● Dehydration give oral rehydration in nontoxic pediatric
or adult patients (see Gastroenteritis Practice Guide)
● IV NS rehydration in all others as needed
● Blood transfusion for bleeding with anemia and
symptomatic volume loss prn
● Anti-emetics prn
● Treatment aimed at cause of syncope or presyncope
Discharge Criteria
● Benign cause of syncope or presyncope in healthy
patient age < 50 years
Discharge instructions
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Syncope or presyncope aftercare instructions
Follow up with PCP within 1–2 days
Consider ambulatory holter monitor
Return if symptoms recur
Consult Criteria
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Syncope or presyncope > 30 seconds
Age ≥ 50 (elderly will usually need hospital admission)
GI bleeding
Acute anemia, or chronic anemia with hemoglobin < 8
gms or a decrease in hemoglobin > 1 gm from
previous levels
Hypotension or tachycardia
O2 sat < 95 on room air or acute dyspnea
Relative hypotension (SBP < 105 with history of
hypertension)
Abnormal EKG
Cardiac dysrhythmia
Positive orthostatics (a normal finding occasionally in
elderly)
Unclear cause of syncope or presyncope
Chest pain or arrhythmia
Comorbid conditions present
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Hypertension
Diabetes
Cardiac
Pulmonary disease
Pregnancy
Pulmonary embolism
DVT
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Neurologic complaints or findings
Toxic ingestion
Dehydration
Fever
Lab and x-ray criteria
● New onset renal insufficiency or worsening chronic
renal insufficiency
● Metabolic acidosis (increased anion gap)
● Hemoglobin decrease > 1 gm or creatinine
increased > 0.5 from baseline
● Elevated LFT’s
● Elevated amylase or lipase
● WBC ≥ 14,000
● Bandemia ≥ 15%
● Significant electrolyte abnormally
● Glucose > 400 mg/dL in diabetic patient
● Glucose > 200 mg/dL in non-diabetic patient
● Acute thrombocytopenia