Syncope, or fainting, is defined as a transient loss of consciousness associated with loss of postural tone that resolves spontaneously. It accounts for 0.8% of ED visits and has a prevalence of 19% in the general population. Common causes include vasovagal, cardiac, orthostatic, and medication-related reactions. A thorough history and physical exam can suggest a diagnosis in 45% of cases and help determine appropriate disposition, whether inpatient for high-risk patients or outpatient follow up for low-risk cases.

1. Al Yaqdhan Al Atbi, MD
EM Resident

2. Outline
• Introduction
• Importance
• Pathophysiology
• Etiology and DDx
• Approach to a patient presented with syncope
• Disposition

3. Introduction
• Syncope or Fainting:
– a transient loss of consciousness, associated with
loss of postural tone, with spontaneous return to
baseline neurologic function requiring no
resuscitative efforts.
• Near-syncope:
– a premonition of fainting without loss of
consciousness

4. Definition

5. Why it is Important
• accounts for 0.8% of ED visits
• prevalence in the general population is 19%.
• Most causes of syncope are benign and have favorable outcomes.
• Recurrence of syncope may be as high as 50% and is not correlated
with age or sex.
• The clinical examination (history and physical examination) alone
can suggest the diagnosis in 45% of cases
• The overall U.S. medical cost of syncope is estimated at $2.4 billion
annually

6. Pathophysiology

9. Etiologies
• Common causes according to Framingham
Heart Study:
– Vasovagal (reflex mediated, 21%)
– cardiac (10%)
– orthostatic (9%)
– Medication related (7%)
– Neurologic (4%)
– unknown (37%).

11. VASOVAGAL AND NEURALLY/REFLEX-
MEDIATED SYNCOPE:
• In appropriate vagal and sympathetic tone
– associated with inappropriate vasodilatation,
bradycardia, or both
– lightheadedness, with or without nausea, pallor,
and/or sweating, and an associated feeling of
warmth
• A slow, progressive onset with associated
prodrome suggests vasovagal syncope.

12. • Exposure to certaine trigger may cause it..
Example:
• unpleasant sight, sound, or smell
• Fear
• severe pain
• emotional distress
• instrumentation
Situational syncope occurs during or immediately after coughing, micturition,
defecation, or swallowing.

15. PSYCHIATRIC DISORDERS
• Organic causes should be rolled out first
• 40% vasovagal syncope & 62% unknown
• Most common Dx:
– generalized anxiety disorder and major depressive
disorder
• Young> elderly

16. NEUROLOGIC SYNCOPE
• Rare
• Patients with loss of consciousness with
persistent neurologic deficits or altered
mental status do not have true syncope.
• Subclavian steal syndrome
• Seizure

19. History
• Age
• Syncopal attack:
– Witnesses/unwitnessed
– Onset , duration , recovary
– Prior to attack
– Attack
– postsyncopal events
– Associated symptoms
• Past medical hx
• Medication HX

22. • Carotid Massage: Carotid sinus Syndrome
• Hyperventilation Maneuver psychiatric (anxiety-provoking)

28. Disposition
• Inpatient:
– If life threaten condition detected
– Farther workup for high risk patient
• Out patient:
– Low risk patients

29. Take Home Message
• Syncope is a common presentation in ED.
• It can indicate for a life threaten conditions.
• The ED evaluation of syncope is often
inconclusive

30. References
• Tintinalli’s
• Rosen