Prehospital management of syncope

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I've noticed that there really isn't very much literature on the topic of syncope in the field, at least not in my EMS textbook. This is kinda shocking to me because it's such a common thing; at least in my experience, I deal with people all the time who "faint".

The main things I do are differentiate cardiac vs. vasovagal, syncope vs. a potential seizure, and also whether or not they really did go unconscious. Of course ruling out head injuries, c-spine injuries, and ensuring normal vitals is important as well.

So does anyone have any other thoughts or suggestions for how to deal with syncope?

Originally Posted by leviathan

So does anyone have any other thoughts or suggestions for how to deal with syncope?

Everyone should be transported to the ED.

I've seen two "psychogenic syncopes" with prolonged QTc's. One of them went into VT during our workup.

Elderly people are particularly at risk for syncope and must be brought to the hospital for:

- cardiac monitoring/telemetry
- CT (institutional dependent) - rarely cause of syncope, but a bilateral (yes bilateral) stroke in my aunt recently changed my view of this
- bilateral carotid duplex ultrasounds
- transthoracic echocardiogram
- EEG (if warranted)
- basic labwork

Prehospital treatment should consist of oxygen if evidence of hypoxia, EKG monitoring, fingerstick glucose, and IV access. If you have time to check orthostatics, then great. I wouldn't stay onscene to stand somebody up for orthostatics, but you can at least check lying to seated orthostatics. Of course if the patient reports dizziness with standing, then they're likely orthostatic and should receive IV fluids.

Originally Posted by southerndoc

Everyone should be transported to the ED.

I've seen two "psychogenic syncopes" with prolonged QTc's. One of them went into VT during our workup.

Elderly people are particularly at risk for syncope and must be brought to the hospital for:

- cardiac monitoring/telemetry
- CT (institutional dependent) - rarely cause of syncope, but a bilateral (yes bilateral) stroke in my aunt recently changed my view of this
- bilateral carotid duplex ultrasounds
- transthoracic echocardiogram
- EEG (if warranted)
- basic labwork

Prehospital treatment should consist of oxygen if evidence of hypoxia, EKG monitoring, fingerstick glucose, and IV access. If you have time to check orthostatics, then great. I wouldn't stay onscene to stand somebody up for orthostatics, but you can at least check lying to seated orthostatics. Of course if the patient reports dizziness with standing, then they're likely orthostatic and should receive IV fluids.

Agree with southerndoc.

Transport to ED.

Syncope is often a frustrating chief complaint because even in the ED you won't often have a definitive answer to "why" they had syncope. Although i think a good rule of thumb is that syncope is cardiac until proven otherwise Ie: gets cardiac workup in right patient.

later

Originally Posted by 12R34Y

Agree with southerndoc.

Transport to ED.

Syncope is often a frustrating chief complaint because even in the ED you won't often have a definitive answer to "why" they had syncope. Although i think a good rule of thumb is that syncope is cardiac until proven otherwise Ie: gets cardiac workup in right patient.

later

This is kinda scary, guys. For those of you who don't know, I volunteer as an EMT at NHL / NBA games, among other things. We've never called for ambulance transport for anyone who passes out except if it was sudden (possibly cardiac), they are symptomatic afterwards, they were elderly, or a combination of the three.

The last case I saw was last week for a 23 yo female who hadn't had anything to eat or drink that day except for two beers. She passed out for 1-2 seconds, if at all, and felt completely fine after and just wanted to be "checked out", so we let her go after taking her vitals and getting her something to eat. To clarify, even if it seems benign like that, you would have recommended transporting her to an ED?

Originally Posted by leviathan

This is kinda scary, guys. For those of you who don't know, I volunteer as an EMT at NHL / NBA games, among other things. We've never called for ambulance transport for anyone who passes out except if it was sudden (possibly cardiac), they are symptomatic afterwards, they were elderly, or a combination of the three.

The last case I saw was last week for a 23 yo female who hadn't had anything to eat or drink that day except for two beers. She passed out for 1-2 seconds, if at all, and felt completely fine after and just wanted to be "checked out", so we let her go after taking her vitals and getting her something to eat. To clarify, even if it seems benign like that, you would have recommended transporting her to an ED?

No, I'm not recommending that you transport every single person who has a syncopal or near syncopal episode to the ED, BUT i do recommend that you try and convince anybody over the age of 40 with syncope to get checked out in the ED.

of course anybody can refuse transport by ambulance, but i still always encouraged those people to go get checked out even if it is on their own.

syncope is tricky. it can be benign, but it sure can bite you in the behind.

later

Originally Posted by 12R34Y

No, I'm not recommending that you transport every single person who has a syncopal or near syncopal episode to the ED, BUT i do recommend that you try and convince anybody over the age of 40 with syncope to get checked out in the ED.

of course anybody can refuse transport by ambulance, but i still always encouraged those people to go get checked out even if it is on their own.

syncope is tricky. it can be benign, but it sure can bite you in the behind.

later

Got it. Thanks for the advice! I did recommend this woman go see her family doctor in the future (mostly to CMA) and to call 911 / go directly to a hospital if she has another episode.

Originally Posted by leviathan

So does anyone have any other thoughts or suggestions for how to deal with syncope?

r/o or treat for dehydration should be on there. I've had a number of pts who passed out at outdoor football games, often in hot weather after limited fluid intake (and often ETOH intake)

Had a quick question for the experts out there. If you are working someone up for syncope, why are carotid duplex done? For example, if you have one sided stenosis, how often do you present with syncope rather than other manifestations? Does anyone have any articles (NEJM or other literature) that supports carotid duplex for work-up of syncope?

Originally Posted by I_love_UMKC

Had a quick question for the experts out there. If you are working someone up for syncope, why are carotid duplex done? For example, if you have one sided stenosis, how often do you present with syncope rather than other manifestations? Does anyone have any articles (NEJM or other literature) that supports carotid duplex for work-up of syncope?

This thread is about the EMS management of syncope. You will probably get better answers to your question if you post it in EM or IM.

Originally Posted by I_love_UMKC

Had a quick question for the experts out there. If you are working someone up for syncope, why are carotid duplex done? For example, if you have one sided stenosis, how often do you present with syncope rather than other manifestations? Does anyone have any articles (NEJM or other literature) that supports carotid duplex for work-up of syncope?

That practice probably is not truly necessary in true syncope.

Originally Posted by leviathan

I've noticed that there really isn't very much literature on the topic of syncope in the field, at least not in my EMS textbook. This is kinda shocking to me because it's such a common thing; at least in my experience, I deal with people all the time who "faint".

The main things I do are differentiate cardiac vs. vasovagal, syncope vs. a potential seizure, and also whether or not they really did go unconscious. Of course ruling out head injuries, c-spine injuries, and ensuring normal vitals is important as well.

So does anyone have any other thoughts or suggestions for how to deal with syncope?

I look at syncope like I look at abdominal pain: There are many causes and some are particularly bad. However, I am fairly limited in my ability to zero in on specific differentials and have limited diagnostic capabilities and will be limited to basic techniques such as a good H&P with vital signs, blood sugar and a XII lead.

I tend to agree with the people who suggest transport.

Originally Posted by leviathan

This is kinda scary, guys. For those of you who don't know, I volunteer as an EMT at NHL / NBA games, among other things. We've never called for ambulance transport for anyone who passes out except if it was sudden (possibly cardiac), they are symptomatic afterwards, they were elderly, or a combination of the three.

The last case I saw was last week for a 23 yo female who hadn't had anything to eat or drink that day except for two beers. She passed out for 1-2 seconds, if at all, and felt completely fine after and just wanted to be "checked out", so we let her go after taking her vitals and getting her something to eat. To clarify, even if it seems benign like that, you would have recommended transporting her to an ED?

even with seemingly benign symptoms in the patient you describe, i would try as much as possible to have her transported. i can just imagine a scenario where after you release her she has another beer or two, falls down and hits her head on the curb. lawyer line of questioning: "so you released her knowing that she had lost consciousness?" "so you released her knowing that she was under the influence of alcohol?" etc etc.

also there are always those rare cases of serious pathology in young people (thinking brugada, long QT, etc.) i like to get 12-leads even on young patients for this reason. even if you pick up on 1 in 1000, thats potentially a life saved. those aren't necessarily pathologies that would be caught every time with an ED visit either. just some food for thought.