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Emergency Department Management of Syncope
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Publication Date: June 2021 (Volume 23, Number 6)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I credits, 4 AAFP Prescribed credits, and 4 AOA Category 2-A or 2-B CME credits. CME expires 06/01/2024.

Authors

James Morris, MD, MPH, FACEP
Program Director, Emergency Medicine Residency, Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX

Peer Reviewers

Deborah Diercks, MD, MS, FACEP, FACC
Professor and Chair, Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX
Marc A. Probst, MD, MS, FACEP
Assistant Professor, Director of Adult Research, Department of Emergency Medicine, Columbia University Irving Medical Center, New York, NY

Abstract

Syncope is the transient loss of consciousness and postural tone, with spontaneous recovery. It accounts for approximately 1% of all emergency department visits and $5.6 billion in healthcare costs annually. In a very small subset of patients, syncope may be a warning sign for serious outcomes or death, but identifying these patients is challenging, as the emergency clinician must distinguish between life-threatening causes and the more common, benign etiologies. Low-yield and expensive testing is often performed, even for benign presentations. Much research on syncope is observational, and clinical decision rules frequently perform poorly in validation studies. This issue reviews the clinical and diagnostic findings that are useful for safely and efficiently identifying patients presenting to the emergency department with syncope.

Case Presentations

CASE 1
A 16-year-old girl is referred to the ED for a head CT after passing out in a doctor’s office…
  • As you review the chart, you note that the girl was in her dermatologist’s office, undergoing excision of a mole, when she became lightheaded and diaphoretic and passed out, without striking her head.
  • She was unconscious less than 1 minute and awoke with no confusion.
  • Because she passed out, the dermatologist told the parents that they should “go immediately to the ER for a CT.” You wonder if that’s really necessary in this case…
CASE 2
A 40-year-old man presents by EMS after what bystanders describe as a “seizure” while he is sitting in a chair…
  • EMS reports that bystanders told them that the man lost consciousness while sitting in a chair, and that he had generalized jerking of his extremities. When EMS arrived a few minutes later, they noted that his mental status was normal, but he was complaining of chest pain and shortness of breath.
  • The patient says that he underwent elective cholecystectomy 3 weeks ago, but denies abdominal pain or vomiting, and he says he has no other medical problems.
  • His vital signs are: blood pressure, 96/54 mm Hg; heart rate, 122 beats/min; respiratory rate, 24 breaths/min; temperature, 37°C; and oxygen saturation, 90% on 2 L nasal cannula.
  • The nurse asks if you want to place the patient on seizure precautions, but you’re not sure that’s his major underlying problem…
CASE 3
An 80-year-old woman presents to the ED after a fall…
  • The patient states she was walking to the bathroom when she found herself on the floor with right knee pain, and no recollection of how she got there. She currently has no other complaints.
  • Her vital signs are normal, and her past medical history is significant for diabetes, hypertension, and heart failure.
  • The x-rays ordered at triage are normal, and she is able to ambulate, but you wonder if there’s something else going on that you should look into before she leaves…

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