Urgent Care Approach to the Syncopal Patient

Table of Contents

 

About This Course

Syncope is the transient loss of consciousness and postural tone, with spontaneous recovery. It accounts for approximately 1% of all emergency department visits. Postsyncopal patients often present to UC and primary care offices after the event, so even nonemergency clinicians must have a systematic, evidence-based approach to evaluate the syncopal patient. 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 clinician must distinguish between life-threatening causes and the more common, benign etiologies. Research on syncope is often observational, and clinical decision rules frequently perform poorly in validation studies. This lack of data leads clinicians to transfer many syncopal patients with benign presentations to the ED. This course reviews the useful clinical and diagnostic findings for safely and efficiently risk-stratifying patients presenting to UC with syncope.

What are the key features that distinguish high-risk syncope from low-risk syncope?

Are risk-stratification tools helpful, and when should they be used?

When is ED transfer appropriate?

1. About This Course
2. Case Presentations
3. Introduction
4. Etiology and Pathophysiology
   1. Neurally Mediated Syncope
   2. Orthostatic Hypotension-Mediated Syncope
   3. Cardiac Syncope
5. Differential Diagnosis
   1. Seizure
6. Urgent Care Evaluation
   1. History
      1. Role of Witnesses to Event
   2. Physical Examination
7. Diagnostic Studies
   1. Electrocardiogram
   2. Laboratory Testing
   3. Imaging and Other Advanced Testing
8. Treatment
   1. Clinical Risk-Stratification Tools
   2. Guidelines
9. Special Populations
   1. Elderly Patients
10. KidBits: The Syncopal Pediatric Patient
11. Controversies
    1. Orthostatic Vital Signs
12. Disposition
    1. High-Risk Patients
    2. Intermediate-Risk Patients
    3. Low-Risk Patients
13. Summary
14. Time and Cost-Effective Strategies
15. Risk Management Pitfalls For Management of Syncope in Urgent Care
16. Critical Appraisal of the Literature
17. Case Conclusions
18. Clinical Pathway for Urgent Care Evaluation of Patients Presenting With Transient Loss of Consciousness
19. References

Case Presentations

CASE 1: A 16-year-old girl is directed to UC after passing out at a pharmacy …

• History reveals that the patient was getting a flu shot at a local pharmacy 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 pharmacist told the parents that they should “go immediately to UC” for evaluation…

CASE 2: A 40-year-old man presents to UC after what witnesses describe as a “seizure” while he is sitting in a chair…

• His wife tells you that the man lost consciousness while sitting in a chair. She states that he had generalized jerking of his extremities. He had a prompt return to normal level of consciousness, but was complaining of chest pain and shortness of breath after the event.
• 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, 92%.
• You wonder what this patient’s major underlying problem is…

CASE 3: A 65-year-old woman presents to UC with complaints of right knee pain after a fall at home…

• 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 and hypertension.
• You wonder if a right knee x-ray is all that’s indicated in this case…

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Introduction

Resulting from global cerebral hypoperfusion, syncope is a transient loss of consciousness (TLOC), typically with associated loss of postural tone, followed by complete, spontaneous recovery. Syncope represents approximately 1% of all emergency department (ED) visits in the United States,¹ but data on urgent care (UC) visits for syncope are incomplete. Annual expenditures for hospital admissions related to syncope are estimated at up to $5.6 billion in the United States.² For most patients with syncope, hospitalization has a much smaller impact on mortality than the patient’s underlying morbidities.³

The primary task of the UC clinician is to distinguish syncope as a presentation of ongoing, life-threatening disease (such as subarachnoid hemorrhage, pulmonary embolism, and hypovolemia secondary to bleeding) from syncope that results from benign causes (such as vasovagal syncope), and from high-risk causes that may have resolved at the time of clinic presentation (particularly arrhythmias).⁴ The most effective tools for evaluating syncope remain the history, physical examination, and electrocardiogram (ECG), as advanced studies have shown vanishingly low yield for most patients with normal examinations and ECGs.^5-10 Several clinical decision rules exist, but their utility has been questioned.^11,12 This issue of Evidence-Based Urgent Care discusses the best available evidence to identify which patients with syncope can be safely discharged with limited testing, and which patients may benefit from further investigation, including ED transfer.

Clinical Pathway for Urgent Care Evaluation of Patients Presenting With Transient Loss of Consciousness

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

4. * Brignole M, Moya A, de Lange FJ, et al. 2018 ESC Guidelines for the diagnosis and management of syncope. Eur Heart J. 2018;39(21):1883-1948 . (Guidelines)

15. * D’Ascenzo F, Biondi-Zoccai G, Reed MJ, et al. Incidence, etiology and predictors of adverse outcomes in 43,315 patients presenting to the Emergency Department with syncope: an international meta-analysis. Int J Cardiol. 2013;167(1):57-62 . (Meta-analysis; 43,315 patients)

27. Chang AM, Hollander JE, Su E, et al. Recurrent syncope is not an independent risk predictor for future syncopal events or adverse outcomes. Am J Emerg Med. 2019;37(5):869-872 . (Prospective observational; 3580 patients)

48. Stockley CJ, Reed MJ, Newby DE, et al. The utility of routine D-dimer measurement in syncope. Eur J Emerg Med. 2009;16(5):256-260 . (Prospective; 237 patients)

59. * Shen WK, Sheldon RS, Benditt DG, et al. 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: a report of the American College of Cardiology/American Heart Association Task 

73. Barón-Esquivias G, Fernández-Cisnal A, Arce-León Á, et al. Prognosis of patients with syncope seen in the emergency room department: an evaluation of four different risk scores recommended by the European Society of Cardiology guidelines. Eur J Emerg Med. 2017;24(6):428-434 . (Prospective observational; 323 patients)

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Keywords: syncope, TLOC, electrocardiogram, ECG, vasovagal, hypotension, orthostatic, cardiac, seizure, dysrhythmia, palpitation, heart failure, Brugada, hypertrophic cardiomyopathy, OEISL score, San Francisco Syncope rule