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symptom.syncope.ed.v1

Syncope (ED workup)

symptomacuteundifferentiatedadultacute
Start encounter →Print handoutPRODUCTION

Phase C shard-3-neuro-sym expansion (2026-05-14) — pattern-matches symptom.chest_pain.ed_undifferentiated.v1 (be7b7d2f) and symptom.vertigo.v1. Engine scope: ED triage + risk-stratification + disposition for the adult syncope presentation. Downstream confirmed diagnoses route to: cardio.afib.core.v1 (arrhythmic), cardio.brady_tachy_syndrome.v1 (sick sinus), cardio.neurally-mediated-reflex-syncope.v1 (vasovagal), cardio.aortic_stenosis.v1 (structural AS), cardio.hcm.chronic.v1 (HCM), cardio.cardiac-tamponade.core.v1 (tamponade), pulm.pe.core.v1 (PESIT PE), cardio.tia.v1 / neuro.ischaemic-stroke.v1 (TIA mimic). Bayesian linkage (LR+, LR−, T_treat, T_test, conditional dependencies, pre-test priors) lives in companion depth bundle _briefs/symptom.syncope.ed.v1.depth.md — schema has no first-class likelihood-ratio field. 10 sibling-differentiation rows cover the key look-alikes (AF arrhythmic / brady-tachy / reflex vasovagal / PE PESIT / AS / HCM / tamponade / TIA / falls / vertigo). 12 severity triggers (≥8 per spec): arrhythmic_syncope_pattern + structural_cardiac_syncope + pesit_pe_pattern + vasovagal_reflex_pattern + orthostatic_syncope + carotid_sinus_hypersensitivity + seizure_mimic + high_risk_ecg + tamponade_syncope + tia_mimic_syncope + hypoglycemia_mimic + high_risk_canadian_syncope_score. Schema-blocked emitted: San Francisco Syncope Rule (Quinn 2006 PMID 16631985) + Canadian Syncope Risk Score (Thiruganasambandamoorthy 2016 PMID 27378464) — both NOT in clinical-tools-registry; manual application + ticketed in shard-3 state file. workup.syncope also missing. Regimen_axes intentionally empty — engine is triage-only. Supportive drug actions (IVF, atropine, adenosine, transfusion, dextrose, deprescribe orthostatic offenders) live in setting_playbooks.ed.drug_actions; definitive treatment is owned by downstream routed engines. Setting playbook: single `ed` per user spec — outpatient syncope clinic is a future engine.

Entry points (8)

  • symptom
    Transient loss of consciousness with spontaneous recovery — ESC 2018 syncope working definition (Brignole PMID 28280232)
    transient_loss_of_consciousness
  • symptom
    Near-syncope / pre-syncope — same risk stratification per Canadian Syncope Risk Score (Thiruganasambandamoorthy CMAJ 2016 PMID 27378464)
    pre_syncope_near_syncope
  • symptom
    Exertional syncope — structural (aortic stenosis, HOCM) until proven otherwise (ESC 2018; ACC/AHA HCM 2024)
    syncope_with_exertion
  • symptom
    Syncope preceded by palpitations — arrhythmic concern (ESC 2018)
    syncope_with_palpitations
  • symptom
    Syncope with chest pain or dyspnea — PE / ACS / dissection / tamponade (Prandoni PESIT NEJM 2016 PMID 27797317; ESC 2018)
    syncope_with_chest_pain_or_dyspnea
  • symptom
    Postural syncope on standing — orthostatic / dehydration / autonomic (Sutton 2013 PMID 21431947)
    orthostatic_syncope
  • symptom
    Cough / micturition / defecation / venipuncture / fear / pain trigger — neurally-mediated reflex (Sheldon HRS 2011 PMID 12103268)
    situational_or_reflex_syncope
  • symptom
    LOC with tongue bite / post-ictal confusion / urinary incontinence — seizure mimic (ESC 2018)
    syncope_with_seizure_features

Required inputs (29)

  • agerequired
    demographic • used at CONTEXT
    Age >60 raises cardiac prior and admission threshold; Canadian Syncope Risk Score age component (Thiruganasambandamoorthy 2016)
  • sexrequired
    demographic • used at CONTEXT
    Vasovagal skews younger female; cardiac causes skew older male
  • prodromerequired
    symptom • used at FRAME
    Vasovagal prodrome (warmth, nausea, diaphoresis, lightheadedness) LR+ ~3 vs absent prodrome which suggests arrhythmic (ESC 2018)
  • posture_at_onsetrequired
    symptom • used at FRAME
    Supine syncope is alarming (arrhythmic / PE / structural); standing syncope is more reflex / orthostatic (Sheldon 2011)
  • triggersrequired
    symptom • used at FRAME
    Cough / micturition / defecation / pain / heat / venipuncture / fear → reflex syncope (Sheldon 2011 PMID 12103268)
  • exertional_triggerrequired
    symptom • used at FRAME
    Exertional syncope = aortic stenosis / HOCM / arrhythmia / catecholaminergic VT until proven otherwise (ESC 2018; ACC/AHA HCM 2024)
  • palpitations_pre_syncoperequired
    symptom • used at ENTRY
    Palpitations preceding LOC raises arrhythmic LR+ ~2.6 (ESC 2018)
  • associated_chest_pain_dyspnearequired
    symptom • used at ENTRY
    Chest pain → ACS / dissection / PE; PESIT (Prandoni NEJM 2016 PMID 27797317) — 17% PE rate in first-time syncope
  • seizure_featuresrequired
    symptom • used at ENTRY
    Tongue bite (LR+ ~17 for seizure) + post-ictal confusion (LR+ ~5) + jerks >30 sec — Sheldon 2011 NMR criteria differentiate
  • head_turn_or_collar_trigger
    symptom • used at CONTEXT
    Carotid sinus hypersensitivity — elderly + head-turn / shaving / tight collar; positive carotid sinus massage diagnostic (ESC 2018)
  • supine_bprequired
    vital • used at CONTEXT
    Supine BP as baseline for orthostatic delta (ESC 2018)
  • standing_bp_1_3minrequired
    vital • used at CONTEXT
    Orthostatic BP drop ≥20 SBP or ≥10 DBP at 1 / 3 min = orthostatic hypotension (Sutton 2013 PMID 21431947)
  • hrrequired
    vital • used at CONTEXT
    Bradycardia / tachycardia clue to arrhythmic etiology
  • spo2required
    vital • used at CONTEXT
    Hypoxia → PE / pulmonary cause (Prandoni 2016 PESIT)
  • cardiac_historyrequired
    history • used at CONTEXT
    Known structural heart disease / prior MI / HF / cardiomyopathy raises arrhythmic prior dramatically (ESC 2018 high-risk feature)
  • family_sudden_deathrequired
    history • used at CONTEXT
    Family hx sudden cardiac death <50 y → channelopathy / HCM / Brugada / long-QT (ACC/AHA HCM 2024)
  • medication_reviewrequired
    history • used at CONTEXT
    QT-prolonging meds (Risk Score CredibleMeds), antihypertensives (orthostatic), diuretics (volume), AV-blockers (bradycardia)
  • volume_status_hxrequired
    history • used at CONTEXT
    Dehydration / GI loss / blood loss → hypovolemic orthostatic syncope
  • vte_risk_factorsrequired
    history • used at CONTEXT
    Recent surgery / immobility / cancer / hormonal / prior VTE → PESIT-style PE workup (Prandoni 2016)
  • pacemaker_icd
    history • used at CONTEXT
    CIED interrogation may reveal arrhythmic syncope (ESC 2018)
  • ecg_12_leadrequired
    imaging • used at INITIAL_WORKUP
    ECG within 10 min — abnormal ECG (any rhythm, conduction, ischemia, QT, Brugada, pre-excitation) is Canadian Syncope Risk Score component (Thiruganasambandamoorthy 2016)
  • fingerstick_glucoserequired
    lab • used at INITIAL_WORKUP
    Hypoglycemia mimics syncope; rapid bedside test (ESC 2018)
  • troponin_hs
    lab • used at INITIAL_WORKUP
    Hs-cTn for ACS as cause of syncope (Thygesen 2018; ESC 2018)
  • hemoglobinrequired
    lab • used at INITIAL_WORKUP
    Acute blood loss / GI bleed as cause of syncope; orthostatic Hb drop (ESC 2018)
  • bnp_nt_probnp
    lab • used at INITIAL_WORKUP
    Canadian Syncope Risk Score includes BNP elevation as cardiac risk feature (Thiruganasambandamoorthy 2016)
  • d_dimer_age_adjusted
    lab • used at BRANCHING_WORKUP
    PESIT-style PE workup — PE in 17% of first-time syncope (Prandoni NEJM 2016 PMID 27797317); ESC 2018 endorses
  • echo_tte
    imaging • used at BRANCHING_WORKUP
    TTE for structural heart disease (AS, HCM, RV dilation, depressed EF, tamponade) — ESC 2018 + ACC/AHA HCM 2024
  • ctpa_chest
    imaging • used at BRANCHING_WORKUP
    CTPA for PE if Wells/PERC positive or PESIT pathway flagged (Prandoni 2016)
  • ct_head_non_contrast
    imaging • used at BRANCHING_WORKUP
    CT head if focal neuro deficit / head trauma during syncope / age >60 with anticoagulation

12-phase flow (12)

  1. 1FRAME
    Confirm true syncope (transient LOC with spontaneous recovery) vs seizure / drop attack / psychogenic; capture prodrome, posture, triggers, exertion link (ESC 2018 PMID 28280232)
    inputs: prodrome, posture_at_onset, triggers, exertional_trigger
    advance: syncope confirmed + classified by trigger pattern
  2. 2ENTRY
    Capture palpitations preceding LOC (arrhythmic), associated chest pain/dyspnea (PE/ACS/dissection per PESIT — Prandoni 2016), seizure features (tongue bite, post-ictal)
    inputs: palpitations_pre_syncope, associated_chest_pain_dyspnea, seizure_features
    advance: entry pattern captured
  3. 3CONTEXT
    Age, sex, cardiac history, FH sudden death, medications, volume status, VTE risks, pacemaker/ICD, head-turn trigger, orthostatic vitals (AHA/ACC/HRS 2017 + ESC 2018)
    inputs: age, sex, supine_bp, standing_bp_1_3min, hr, spo2, cardiac_history, family_sudden_death, medication_review, volume_status_hx, vte_risk_factors, pacemaker_icd, head_turn_or_collar_trigger
    advance: context complete
  4. 4RED_FLAGS
    High-risk features (ESC 2018): syncope during exertion / supine; severe structural HD; sudden palpitations preceding; abnormal ECG (any rhythm, AV block, long/short QT, Brugada, pre-excitation, ischemia); FH SCD <50 y; new chest pain / dyspnea / neuro deficit
    inputs: ecg_12_lead
    advance: no high-risk features OR routed to dedicated downstream engine / admit
  5. 5INITIAL_WORKUP
    12-lead ECG within 10 min, orthostatic vitals, fingerstick glucose, CBC + Hb, BMP, hs-troponin if cardiac concern; consider BNP (ESC 2018; Canadian Syncope Risk Score features)
    inputs: ecg_12_lead, fingerstick_glucose, hemoglobin, troponin_hs, bnp_nt_probnp
    actions: panel.cardiac, panel.cbc, panel.renal
    advance: initial workup reviewed
  6. 6BRANCHING_WORKUP
    Pivot on findings: abnormal ECG / palpitations / structural concern → TTE + telemetry; PESIT pathway → Wells PE + age-adjusted D-dimer → CTPA (Prandoni 2016); orthostatic + volume → IVF rehydration; reflex pattern → outpatient tilt-table (Sutton 2013); head trauma or focal neuro → CT head
    inputs: d_dimer_age_adjusted, echo_tte, ctpa_chest, ct_head_non_contrast
    advance: branching workup pivots to disposition route
  7. 7DIFFERENTIAL
    Vasovagal / reflex (~40-50%) / cardiac arrhythmic (~15-25%) / orthostatic (~10-15%) / structural (AS, HOCM, tamponade) / PE (~17% per PESIT — Prandoni 2016) / TIA mimic (rare without focal deficit) / seizure mimic / psychogenic / unknown (~10%) — ESC 2018 priors
    advance: differential ranked with pre-test priors documented
  8. 8RISK_STRATIFICATION
    Canadian Syncope Risk Score (Thiruganasambandamoorthy CMAJ 2016 PMID 27378464) and San Francisco Syncope Rule (Quinn 2006 PMID 16631985) — both schema-blocked (not in registry); PE workup via Wells/PERC/sPESI; HEART if cardiac chest pain overlay (ESC 2018)
    inputs: age
    actions: calc.wells_pe, calc.perc, calc.spesi, calc.heart
    advance: risk scores documented
  9. 9TREATMENT
    Supportive at this layer: IVF for orthostatic / volume depletion; physical counterpressure maneuvers for vasovagal (Sheldon 2011); fludrocortisone / midodrine for refractory orthostatic; reverse anticoag if intracranial bleeding from fall; defer definitive to downstream engine
    advance: supportive Rx initiated
  10. 10DISPOSITION
    High-risk → admit (telemetry); intermediate → observation unit + outpatient cardiac workup; low-risk vasovagal → discharge with education + outpatient follow-up; PE confirmed → pulm.pe; arrhythmic → cardio.afib / brady_tachy; reflex pattern → cardio.neurally-mediated-reflex-syncope; structural → cardio.aortic_stenosis or cardio.hcm.chronic; tamponade → cardio.cardiac-tamponade (ESC 2018; AHA/ACC/HRS 2017 PMID 28280232)
    advance: disposition assigned + downstream handoff complete
  11. 11MONITORING
    Telemetry continuous if admitted; orthostatic vitals every shift; serial ECG if dynamic abnormality; CIED interrogation for known device (ESC 2018)
    inputs: ecg_12_lead
    advance: monitoring trend captured
  12. 12FOLLOWUP
    Discharged low-risk: outpatient cardiology / EP / neurology / tilt-table per phenotype within 7-14 d; reflex syncope education; driving counseling per local regs; medication adjustment (taper QT-prolonging / orthostatic offenders)
    advance: discharge bundle prescribed + follow-up scheduled