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symptom.syncope.ed.v1PRODUCTION
symptom.syncope.ed.v1

Syncope (ED workup)

symptomacuteundifferentiatedadult
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Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm true syncope (transient LOC with spontaneous recovery) vs seizure / drop attack / psychogenic; capture prodrome, posture, triggers, exertion link (ESC 2018 PMID 28280232)

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Advance rule
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syncope confirmed + classified by trigger pattern

Patient inputs (29)

Age >60 raises cardiac prior and admission threshold; Canadian Syncope Risk Score age component (Thiruganasambandamoorthy 2016)

Vasovagal skews younger female; cardiac causes skew older male

Supine BP as baseline for orthostatic delta (ESC 2018)

Orthostatic BP drop ≥20 SBP or ≥10 DBP at 1 / 3 min = orthostatic hypotension (Sutton 2013 PMID 21431947)

Bradycardia / tachycardia clue to arrhythmic etiology

Hypoxia → PE / pulmonary cause (Prandoni 2016 PESIT)

Known structural heart disease / prior MI / HF / cardiomyopathy raises arrhythmic prior dramatically (ESC 2018 high-risk feature)

Family hx sudden cardiac death <50 y → channelopathy / HCM / Brugada / long-QT (ACC/AHA HCM 2024)

QT-prolonging meds (Risk Score CredibleMeds), antihypertensives (orthostatic), diuretics (volume), AV-blockers (bradycardia)

Dehydration / GI loss / blood loss → hypovolemic orthostatic syncope

Recent surgery / immobility / cancer / hormonal / prior VTE → PESIT-style PE workup (Prandoni 2016)

Palpitations preceding LOC raises arrhythmic LR+ ~2.6 (ESC 2018)

Chest pain → ACS / dissection / PE; PESIT (Prandoni NEJM 2016 PMID 27797317) — 17% PE rate in first-time syncope

Tongue bite (LR+ ~17 for seizure) + post-ictal confusion (LR+ ~5) + jerks >30 sec — Sheldon 2011 NMR criteria differentiate

Vasovagal prodrome (warmth, nausea, diaphoresis, lightheadedness) LR+ ~3 vs absent prodrome which suggests arrhythmic (ESC 2018)

Supine syncope is alarming (arrhythmic / PE / structural); standing syncope is more reflex / orthostatic (Sheldon 2011)

Cough / micturition / defecation / pain / heat / venipuncture / fear → reflex syncope (Sheldon 2011 PMID 12103268)

Exertional syncope = aortic stenosis / HOCM / arrhythmia / catecholaminergic VT until proven otherwise (ESC 2018; ACC/AHA HCM 2024)

ECG within 10 min — abnormal ECG (any rhythm, conduction, ischemia, QT, Brugada, pre-excitation) is Canadian Syncope Risk Score component (Thiruganasambandamoorthy 2016)

Hypoglycemia mimics syncope; rapid bedside test (ESC 2018)

Acute blood loss / GI bleed as cause of syncope; orthostatic Hb drop (ESC 2018)

PESIT-style PE workup — PE in 17% of first-time syncope (Prandoni NEJM 2016 PMID 27797317); ESC 2018 endorses

TTE for structural heart disease (AS, HCM, RV dilation, depressed EF, tamponade) — ESC 2018 + ACC/AHA HCM 2024

CTPA for PE if Wells/PERC positive or PESIT pathway flagged (Prandoni 2016)

CT head if focal neuro deficit / head trauma during syncope / age >60 with anticoagulation

Carotid sinus hypersensitivity — elderly + head-turn / shaving / tight collar; positive carotid sinus massage diagnostic (ESC 2018)

CIED interrogation may reveal arrhythmic syncope (ESC 2018)

Hs-cTn for ACS as cause of syncope (Thygesen 2018; ESC 2018)

Canadian Syncope Risk Score includes BNP elevation as cardiac risk feature (Thiruganasambandamoorthy 2016)

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Severity triggers (12)

12 need judgement
  • informationallife_threateningstructural_cardiac_syncope
    Exertional syncope + systolic murmur (aortic stenosis or HCM LVOT) OR known severe AS/HOCM/depressed EF (ESC 2018; ACC/AHA HCM 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningtamponade_syncope
    Syncope + Beck triad (hypotension + JVD + muffled heart sounds) + pulsus paradoxus >10 + pericardial effusion on POCUS (ESC 2015 Pericardial Disease)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverearrhythmic_syncope_pattern
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepesit_pe_pattern
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehigh_risk_ecg
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveretia_mimic_syncope
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehypoglycemia_mimic
    LOC with fingerstick glucose <70 + diabetic on insulin/sulfonylurea + Whipple triad satisfied (ADA 2026)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehigh_risk_canadian_syncope_score
    Canadian Syncope Risk Score ≥1 OR San Francisco Syncope Rule positive (Quinn 2006 PMID 16631985; Thiruganasambandamoorthy CMAJ 2016 PMID 27378464)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateorthostatic_syncope
    Postural BP drop ≥20 SBP or ≥10 DBP at 1 or 3 min standing + symptom reproduction + identifiable cause (dehydration, autonomic dysfunction, medication, blood loss) (Sutton 2013 PMID 21431947)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatecarotid_sinus_hypersensitivity
    Elderly patient (>50) with syncope on head turn / shaving / tight collar; carotid sinus massage produces asystole >3 s OR SBP drop >50 (ESC 2018)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateseizure_mimic
    LOC with tongue bite (LR+ ~17 for seizure) + post-ictal confusion (LR+ ~5) + sustained rhythmic jerks >30 s + head turn during episode + urinary incontinence (Sheldon 2011)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildvasovagal_reflex_pattern
    Classic vasovagal: prodrome (warmth, nausea, diaphoresis, lightheadedness) + provoking trigger (prolonged standing, pain, emotion, venipuncture) + rapid recovery (Sheldon HRS 2011 PMID 12103268)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

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RISK_STRATIFICATIONrequiredDrives risk stratification
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Recommended regimen

ed playbook — drug actions (5)

  1. 1. isotonic crystalloid
    500-1000 mL bolus then reassess • IV • titrate to orthostatic resolution
    trigger: Orthostatic syncope with volume depletion (postural BP drop + dry mucosa + tachycardia)
    ESC 2018 — first-line for orthostatic / hypovolemic syncope
  2. 2. pRBC transfusion
    1-2 units • IV • reassess Hb
    trigger: Hb <7 (or <8 with cardiac disease) AND ongoing bleeding source
    AABB 2023 restrictive transfusion threshold; correct anemic syncope
  3. 3. atropine
    rxcui 1223
    0.5-1 mg IV • IV • q3-5 min PRN max 3 mg
    trigger: Symptomatic bradycardia <50 with hypotension
    ACLS 2025 — first-line for symptomatic bradycardia; ineffective for high-grade AV block (use transcutaneous pacing)
  4. 4. adenosine
    rxcui 296
    6 mg IV rapid push then 12 mg • IV • q2 min PRN
    trigger: Stable narrow-complex SVT
    ACLS 2025 — first-line vagal-refractory SVT
  5. 5. discontinue offending med
    N/A • discontinue • once
    trigger: Polypharmacy with antihypertensive / diuretic / QT-prolonger / alpha-blocker
    AGS Beers 2023 — orthostatic-causing drugs in elderly; deprescribe in syncope context

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: Transient loss of consciousness with spontaneous recovery — ESC 2018 syncope working definition (Brignole PMID 28280232); 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).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Syncope (ED workup)** (symptom.syncope.ed.v1).
Phenotype framing: 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
Scope: Confirm true syncope (transient LOC with spontaneous recovery) vs seizure / drop attack / psychogenic; capture prodrome, posture, triggers, exertion link (ESC 2018 PMID 28280232)

No severity triggers fired against current inputs.

Plan

No regimen axis selected (engine has no regimen_axes or could not match).

Setting playbook (ed) — Triage + risk-stratify syncope by ESC 2018 + AHA/ACC/HRS 2017 high-risk features; rule out PE (PESIT pathway — Prandoni 2016), arrhythmia, structural, orthostatic; admit high-risk; discharge low-risk with outpatient referral (Canadian Syncope Risk Score / SFSR)
1. isotonic crystalloid 500-1000 mL bolus then reassess IV titrate to orthostatic resolution — Orthostatic syncope with volume depletion (postural BP drop + dry mucosa + tachycardia) (ESC 2018 — first-line for orthostatic / hypovolemic syncope)
2. pRBC transfusion 1-2 units IV reassess Hb — Hb <7 (or <8 with cardiac disease) AND ongoing bleeding source (AABB 2023 restrictive transfusion threshold; correct anemic syncope)
3. atropine 0.5-1 mg IV IV q3-5 min PRN max 3 mg — Symptomatic bradycardia <50 with hypotension (ACLS 2025 — first-line for symptomatic bradycardia; ineffective for high-grade AV block (use transcutaneous pacing))
4. adenosine 6 mg IV rapid push then 12 mg IV q2 min PRN — Stable narrow-complex SVT (ACLS 2025 — first-line vagal-refractory SVT)
5. discontinue offending med N/A discontinue once — Polypharmacy with antihypertensive / diuretic / QT-prolonger / alpha-blocker (AGS Beers 2023 — orthostatic-causing drugs in elderly; deprescribe in syncope context)

Non-pharmacologic actions:
- Continuous cardiac telemetry during ED stay
- Two IVs; type & screen if bleeding suspected
- Cardiology consult if high-risk ECG or structural concern
- Neurology consult if seizure suspicion or focal deficit
- CIED interrogation if pacemaker/ICD
- Physical counterpressure maneuvers education for vasovagal
- Driving counseling per local regulations

Monitoring

Setting (ed) monitoring:
- Continuous ECG telemetry
- BP every 30 min × 2 h then per disposition
- SpO2 continuous
- Repeat orthostatic vitals before discharge
- Reassess after IVF / atropine / adenosine response

Follow-up plan: 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)
- Close-out criterion: discharge bundle prescribed + follow-up scheduled

Monitoring phase: Telemetry continuous if admitted; orthostatic vitals every shift; serial ECG if dynamic abnormality; CIED interrogation for known device (ESC 2018)

Disposition

Current setting: ed — Triage + risk-stratify syncope by ESC 2018 + AHA/ACC/HRS 2017 high-risk features; rule out PE (PESIT pathway — Prandoni 2016), arrhythmia, structural, orthostatic; admit high-risk; discharge low-risk with outpatient referral (Canadian Syncope Risk Score / SFSR)

Disposition criteria:
- Discharge: vasovagal / reflex / orthostatic with reversible cause, Canadian Syncope Risk Score low (-3 to -1) AND San Francisco Syncope Rule negative AND no high-risk ECG, reliable follow-up ≤7-14 d
- Observation: intermediate-risk; awaiting trop trend / telemetry; suspected PE pending CTPA result
- Admit telemetry: ANY ESC 2018 high-risk feature — exertional syncope, supine syncope, severe structural HD, abnormal ECG (any rhythm/conduction/QT/Brugada/ischemia), FH SCD <50, persistent vital instability
- ICU: hemodynamic instability, intubation, post-arrest, massive PE on thrombolytics

Escalation triggers (move to higher acuity):
- Sustained VT / unstable arrhythmia → ACLS protocol + cardiology + ICU
- High-grade AV block (Mobitz II / complete) → transcutaneous pacing + transvenous pacer + cardiology → cardio.brady_tachy_syndrome.v1
- Massive PE with hypotension → systemic thrombolysis → route to pulm.pe.core.v1 (PEITHO PMID 24716681)
- Aortic stenosis with exertional syncope → urgent echo + cardiology → cardio.aortic_stenosis.v1
- HCM with FH SCD or LVOT obstruction → ICD consideration + EP referral → cardio.hcm.chronic.v1
- Tamponade physiology on POCUS → emergent pericardiocentesis → cardio.cardiac-tamponade.core.v1
- Focal neuro deficit + syncope → stroke pathway → neuro.ischaemic-stroke.v1 or cardio.tia.v1

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Exertional syncope + systolic murmur (aortic stenosis or HCM LVOT) OR known severe AS/HOCM/depressed EF (ESC 2018; ACC/AHA HCM 2024)
- [LIFE_THREATENING] Syncope + Beck triad (hypotension + JVD + muffled heart sounds) + pulsus paradoxus >10 + pericardial effusion on POCUS (ESC 2015 Pericardial Disease)
- [SEVERE] 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)

Citations

- 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 [PMID:28280232](https://pubmed.ncbi.nlm.nih.gov/28280232/)
- Cited evidence (PMID 30470687) [PMID:30470687](https://pubmed.ncbi.nlm.nih.gov/30470687/)

Last reconciled with current guidelines: 2026-05-30.
References
  • 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 — PMID:28280232
  • Cited evidence (PMID 30470687) — PMID:30470687