This document provides information on evaluating and managing patients presenting with syncope (transient loss of consciousness). It describes the initial assessment including ABCs, vital signs and ECG. It outlines key questions to determine if it is true syncope, identify the cause, and assess risk of serious outcomes. Causes are categorized as high, moderate or low risk. Evaluation involves establishing the diagnosis, identifying triggers, risk factors and ruling out conditions like arrhythmias. Scoring systems like SFSR and ROSE can stratify risk. Prolonged QT interval may indicate conditions like long QT syndrome or Brugada syndrome. Management involves stabilizing and monitoring patients or transferring to higher levels of care based on risk level.

1. Dr Ng JoYe
Syncopal Attack

2. What is Syncope ?
Transient loss of conciousness (TLOC) attributable to global
cerebral hypoperfusion, characterized by
Rapid onset
Brevity
Spontaneous recovery

5. Initial management
ABC
Vital sign and ECG
IV line if suspicious of volume loss

6. Patient Assessment
The initial evaluation should answer three key question .
Is this a true syncope ?
Has the aetiological diagnosis been determined?
Are there data suggestive a high risk of cardiovascular
events or death?

7. 1. Diagnosis of syncope
Was LOC complete ?
Was LOC transient with rapid onset and short duration ?
Did the patient recovery spontaneously, completely and
without sequelae?
Did the patient lose postural tone ?

8. 2. Aetiology diagnosis
Questions about circumstances just prior to attack
Position (supine, sitting , standing)
Activity (rest, change in posture, during or immediately after
exercise, during or immediately after urination, defecation
or swallowing)
Predisposing factors (crowded or warm place, prolonged
standing post-prandial period) and of precipitating events
(fear, intense pain, neck movements)
Questions about onset of the attack
Nausea, vomiting, feeling cold, sweating, pain in chest, pain
in neck, or shoulders,

9. Questions about attack (eye witness)
Skin color (pallor, cyanotic)
Duration of loss of consciousness
Movements ( tonic-clonic, etc.)
Tongue biting
Questions about the end of the attack
Nausea, vomiting, diaphoresis, feeling cold, muscle aches,
confusion, skin color, wounds

10. Questions about background
Number and duration of syncope spells
Family history of arrhythmic disease or sudden death
Presence of cardiac disease
Neurological disease (Parkinsons, epilepsy, narcolepsy)
Internal history (Diabetes)
Medications (Hypotensive, negative chronotropic and
antidepressant agents)

11. 3. Risk stratification
San Francisco Syncope Rule (SFSR)
C – congestive heart failure
H – Hematocrit < 30 %
E – ECG abnormal
S – shortness of breath
S – systolic < 90mmHg at triage
Sensitivity : 98%, specificity 56 %
Risk of serious outcome or death at 30 days

12. 3. Risk stratification
 ROSE (Risk Stratification of Syncope in the Emergency
Department)
B - Brain natriuretic peptide level ≥ 300 pg per mL
- Bradycardia < 50 bpm
R – rectal examination ( fecal occult blood )
A – Anemia < 9g/L
C – Chest pain associated with syncope
E – ECG (Q wave not on lead III)
S – saturation < 94 % under RA
Sensitivity : 87%, specificity 66 %
Risk of serious outcome or death at 30 days

13. 3. Risk stratification
OESIL (Osservatorio Epidemiologico sulla Sincope nel Lazio)
Age > 65 years old
History of cardiovascular disease
Syncope without a prodrome
Abnormal ECG
risk of all-cause mortality at 12 months

14. High Risk category
 AMI
 Myocarditis
 Dysrhythmias
 Second and third degree heart
block
 Pacemaker dysfunction
 VT
 Prolonged QT syndrome
 Brugada syndrome
 Ectopic pregnancy
 Antepartum haemorrhage
 Severe GI bleed
 Pulmonary embolism
 SAH
Actions :
1. Transfer patient to resus
2. Immediate resuscitation
3. Consider admission to ICU
4. Refer to relevant discipline stat .

15. Long QT syndrome
Bazett: 1920 QTc=QT/square root of the RR
Abnormal if QTc in males >470 ms and females of > 480 ms
Borderline prolonged QTc 450-470 ms
Average QTc for someone with the LQTS is 490 ms

17. Causes of prolonged QT interval
Drugs : Antidysrhythmics (eg: quinidine, procainamide,
disopyramide, sotalol and amiodarone). Psychotropic agents
Electrolyte abnormalities : hypo K, Mg,Ca
Cardiac abnormalities : MI, Myocarditis
Intracranial Disease : SAH
Altered nutritional state : Liquid protein modified fast diet/
starvation
Congenital : Jervell and Lange- Nielsen syndrome , Romano-
Ward syndrome, Sporadic type

18. Diagnostic Criteria for LQTS
 EKG findings
 QTc
 >480 3
 460-470 2
 450 (male) 1
 Torsdade De Pointes 2
 T-wave alternans 1
 Notched T wave in 3 leads 1
 Low heart rate for age 0.5
 Clinical History
 Syncope with stress 2
without stress 1
 Congenital deafness 0.5
 Family history
 Definite LQTS 1
 Unexplained SCD in immediate family member that is less than 30 years of age
0.5

19. <1 points low probability
2-3 points intermediate probability
 >4 points high probability

20. Brugada syndrome
Cause of Sudden Unexplained Nocturnal Death Syndrome in
SEA

21. Brugada syndrome diagnostic criteria
1. Type 1 ECG pattern in > 2 precordial leads (V1-V3), in
conjunction with one of the following :
 Documented VF
 Polymorphic VT
 Family hx of sudden cardiac death < 45 yo
 Coved type ECG in family member
 Syncope
 Nocturnal agonal respiration
 Inducibility of VT with programmed electrial stimulation
2. Conversion of type 2/3 to type 1 after Sodium blocker
administration in conjuntion with above clinical features

23. Moderate Risk category
 Aortic stenosis
 Hypertropic obstructive
cardiomyopathy (exertional
syncope)
 Suspected mild CVA / TIA
 Mild blood loss
 Orthostatic syncope (volume loss)
 Hypoglycemia
 Patients with IHD
 CCF
 SVT
 Drug induced syncope
Actions :
1. Stablilize the patient
2. Consider admitting the patient to observation unit.

24. Low Risk category
 Vasovagal/neurocardiogenic
syncope eg :
 Micturation/defaecation syncope
 Postprandial
 Tussive
 Psychogenic syncope
 Anxiety and panic disorder
 Unexplained syncope
Actions :
1. Excluded all high risk and moderate risk condition
2. Observe > 2 hrs
3. Discharge if the patient is alert and attentive and parameters are stable
4. For patient with recurrent vasovagal syncope, consider referral to cardiology.

25. Actions :
1. Transfer patient to resus
2. Immediate resuscitation
3. Consider admission to ICU
4. Refer to relevant discipline stat .

27. References
Shirley O, Sim TB. Syncope. Guide to The Essentials in
Emergency Medicine.
European Heart Journal (2009) Guideline for the diagnosis
and management of syncope.
Saklani et al. American Heart Association. Ciruculation
2013: syncope