I. Initial Evaluation

History

• Symptoms: Transient loss of consciousness with spontaneous recovery; presyncope symptoms include dizziness, lightheadedness, nausea, diaphoresis, visual changes
• Onset: Sudden vs gradual; during exertion, positional changes, or emotional stress
• Associated signs: Chest pain, palpitations, incontinence, tongue biting, postictal confusion
• Past history: Cardiac disease, arrhythmias, prior syncope, family history of sudden death

Physical Exam

• Vitals: Look for orthostatic hypotension, bradycardia, tachyarrhythmias
• Cardiac: Murmurs (e.g., HOCM, AS), irregular rhythm
• Neurologic: Focal deficits (consider stroke or seizure)
• Signs of trauma: Head injury from fall during syncopal event

II. Diagnostic Workup

EKG

• Arrhythmias: Bradycardia, tachycardia, pauses
• Conduction abnormalities: AV blocks, WPW, QT prolongation
• Ischemic changes: ST depressions/elevations
• Signs of Brugada, ARVD, or other syndromes

Labs

• Glucose (hypoglycemia)
• Electrolytes (K⁺, Mg²⁺, Na⁺)
• Hematocrit (anemia)
• Troponin if ischemia suspected
• Beta-hCG in females of childbearing age

Imaging

• Chest X-ray: CHF, pneumonia, aortic pathology
• Head CT: If concern for trauma or focal neurologic deficit or first time seizure
• Echo: Suspected structural heart disease, consider if the patient is admitted

III. Classification of Syncope Etiologies

Category	Examples
Reflex (neurally mediated)	Vasovagal, situational (cough, micturition), carotid sinus hypersensitivity
Orthostatic	Volume depletion, autonomic dysfunction, medications
Cardiac	Arrhythmias, structural heart disease, valve disease, MI
Neurologic / Other	Seizures, stroke, subclavian steal, psychogenic, ruptured ectopic

IV. Treatment and Management

Immediate Stabilization

• Ensure airway, breathing, circulation
• Assess for trauma from fall
• Cardiac monitoring and IV access

Etiology-Specific Management

• Reflex syncope: Reassurance, avoid triggers, hydration
• Orthostatic hypotension: Fluids, adjust medications, compression stockings
• Cardiac cause: Admission, Treat underlying arrhythmia or structural lesion, consult cardiology

V. Disposition Planning

San Francisco Syncope Rule (CHESS)

• Congestive heart failure history
• Hematocrit < 30%
• EKG abnormal
• Shortness of breath
• Systolic BP < 90 mmHg at triage

Presence of any predictor indicates increased risk of serious outcome within 7 days. Consider admission if any of the criteria are positive.

Scenario	Disposition	Notes
Low-risk syncope, normal workup, reassuring history	Discharge with outpatient follow-up	Provide return precautions and guidance
High-risk features: exertional syncope, cardiac history, abnormal EKG, persistent symptoms	Admit to telemetry or step-down	Consider EP or cardiology consult

VI. Red Flags / Escalation Triggers

• Syncope during exertion or while supine
• Chest pain, palpitations, or SOB prior to event
• Family history of sudden cardiac death
• Prolonged loss of consciousness or seizure activity
• Abnormal EKG suggestive of arrhythmia or ischemia

✅ Discharge Checklist

• Stable vitals, normal EKG, no concerning features
• Discussed avoidance of triggers (dehydration, prolonged standing)
• Follow-up with PCP or cardiology
• Return precautions for recurrent events or worsening symptoms

References

1. Shen WK, Sheldon RS, Benditt DG, et al. 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope. J Am Coll Cardiol. 2017;70(5):e39–e110. https://doi.org/10.1016/j.jacc.2017.03.003