Patient handout

Syncope (ED workup)

PRODUCTION

1. Your condition

This handout is for syncope (ed workup). Your care team identified this based on: transient loss of consciousness with spontaneous recovery — esc 2018 syncope working definition (brignole pmid 28280232).

Other reasons your team may use this plan: near-syncope / pre-syncope — same risk stratification per canadian syncope risk score (thiruganasambandamoorthy cmaj 2016 pmid 27378464); exertional syncope — structural (aortic stenosis, hocm) until proven otherwise (esc 2018; acc/aha hcm 2024); syncope preceded by palpitations — arrhythmic concern (esc 2018).

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Syncope without prodrome OR during exertion OR supine + abnormal ECG (any rhythm, conduction, ischemia, long-QT, Brugada, pre-excitation) (ESC 2018 PMID 28280232; AHA/ACC/HRS 2017)
Exertional syncope + systolic murmur (aortic stenosis or HCM LVOT) OR known severe AS/HOCM/depressed EF (ESC 2018; ACC/AHA HCM 2024)(life-threatening)
First-time syncope + ≥1 of: tachycardia, hypoxia, recent immobility, prior VTE, malignancy, hormonal therapy → PESIT pathway (Prandoni NEJM 2016 PMID 27797317 — PE found in 17% of admitted syncope)
New abnormal ECG: bifascicular block + 1° AV block, Mobitz II / complete AV block, long QT >480 ms (men) / >500 (women), short QT <340 ms, Brugada type 1, pre-excitation (WPW), epsilon waves (ARVC), ischemic changes (ESC 2018)
Syncope + Beck triad (hypotension + JVD + muffled heart sounds) + pulsus paradoxus >10 + pericardial effusion on POCUS (ESC 2015 Pericardial Disease)(life-threatening)
Syncope with focal neuro deficit (hemiparesis, aphasia, hemisensory, diplopia, dysarthria, ataxia) OR vertebrobasilar features (subclavian steal pattern with arm exertion) (AHA/ASA 2021 PMID 34024117)
LOC with fingerstick glucose <70 + diabetic on insulin/sulfonylurea + Whipple triad satisfied (ADA 2026)
Canadian Syncope Risk Score ≥1 OR San Francisco Syncope Rule positive (Quinn 2006 PMID 16631985; Thiruganasambandamoorthy CMAJ 2016 PMID 27378464)

5. Follow-up

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)

6. Sources

Guideline: 2018 ESC Syncope Guideline (Brignole) + 2017 AHA/ACC/HRS Syncope Evaluation (Shen) + PESIT (Prandoni NEJM 2016) + San Francisco Syncope Rule (Quinn 2006) + Canadian Syncope Risk Score (Thiruganasambandamoorthy CMAJ 2016) + Sheldon HRS 2011 NMR + Sutton 2013 tilt-table