Syncope evaluation in ED

  or   ?

One of the greatest mysteries is that during syncope, transient cerebral hypoperfusion can cause transient muscular jerking. Onlookers may think this is a seizure and report it as so.

Syncope vs seizure


Which patients should be admitted for further investigations?

Risk stratifying scoring systems:


Good sens but overall poor spec

  • Recent meta-analysis showed that the scoring systems are not better than clinical judgement.

Red Flags for syncope


Causes of syncope:



  • I will skip this because based on your suspicion, a series of tests will be performed to rule out the most life threatening diseases.
  • One special note on use of carotid doppler
    – Carotid stenosis causes TIA (transient focal deficits or visual problems) without syncope
    – To have syncope, you need to have ischemia to areas supplied by posterior circulation (bilateral carotid artery stenosis or TIA of vertebrobasilar system). These are the areas governing our consciouness.
    – In TIA of VBS, Ds symptoms will be present (diplopia, dysphagia, dysarthria, dystaxia aka ataxia)
    – Carotid doppler is not always required, but if it’s done, carotid artery stenosis is often a co-existing disease
  • CT scan in syncope:
    – Routine neuroimaging is not indicated
    – Only if there are red flags SNOOP (derived from headache):
    i) Suddden headache
    ii) Neurological deficits
    iii) Older > 65
    iv) Onset (with SOB, chest pain, tachycardia, syncope during exertion etc)
    v) Predisposition (history of SCD, cardiac disease, taking warfarin etc)



ROBERT L. GAUER, MD, Womack Army Medical Center, Fort Bragg, North Carolina. Evaluation of Syncope. American Family Physician, September 15, 2011; 84(6):640-50

Andrew McKeon, Carl Vaughan, Norman Delanty. Seizure versus syncope. Lancet Neurol 2006; 5: 171–80.

Costantino G, Casazza G, Reed M, Bossi I, Sun B, Del Rosso A, Ungar A, Grossman S, D’Ascenzo F, Quinn J, McDermott D, Sheldon R12, Furlan R. Syncope risk stratification tools vs clinical judgment: an individual patient data meta-analysis. Am J Med. 2014 Nov;127(11):1126.e13-25


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