This document outlines a syncope protocol developed for a geriatric trauma center. The protocol provides guidelines for evaluating geriatric trauma patients presenting with syncope. It describes performing an ECG, orthostatic blood pressure check, and labs as part of the initial evaluation. Patients are then stratified as high cardiac risk or non-cardiac/low risk based on history and tests. Those at high risk may require admission, cardiology consult, and further testing. The goal is to safely determine the cause of syncope and avoid unnecessary testing or admission.

1. First Annual G- 60 Geriatric
Trauma Conference
Development of Syncope Protocol
Mary Collins, MS, FNP-C, AGACNP-BC
Trauma/ Acute Care Nurse Practitioner
John C. Lincoln Hospital
G60 TRAUMA

2. Syncope Protocol
Multiple Syncope Studies
• San Francisco Syncope Rule
• ROSE Study
• STePS
• Boston Syncope Rule
• SEEDS study
G60 TRAUMA

3. Syncope Protocol
San Francisco Syncope Rule
2004 Quinn,J, McDermott, Stiell,I et al
Prospective cohort study
684 visits for syncope- f/u for 7 days, later study 30 days
CHESS
C CHF history
H Hematocrit < 30%
E ECG abnormality—new, any non-sinus rhythm
S Shortness of breath
S Systolic BP < 90mm Hg
18% who had 1 predictor had serious outcome
Annals of Emergency Medicine Feb. 43 (2):224-232
G60 TRAUMA

4. Syncope Protocol
ROSE Rule
2010 Reed, Coul, Jacques et al
Single Center prospective observational study
N=550
High Risk = positive answer to any of 7 Criteria
BRACES criteria:
B BNP > 300
Bradycardia < 50 bpm
R Rectal Exam (FOBT positive)
A Anemia hemoglobin <9
C Chest Pain with Syncopal event
E ECG + Q waves
S SpO2 < 94% on RA
Journal of American College of Cardiology 55(8): 713-721
G60 TRAUMA

5. G-60 Syncope Protocol
AHA/ ACCF Scientific Statement of
the Evaluation of Syncope: From the
American Heart Association Councils on Clinical
Cardiology, Cardiovascular Nursing,
Cardiovascular Disease in the Young, and
Stroke, and the Quality of Care and Outcomes
Research Interdisciplinary Working Group; and
the America College of Cardiology Foundation:
In Collaboration With the Heart Rhythm Society:
Endorsed by the American Autonomic Society.
Strickberger, S, Benson, D, Biaggioni, I. et al (2006) Circulation; 113:316-327
G60 TRAUMA

6. G-60 Syncope Protocol
Guidelines for the diagnosis and
management of syncope (version
2009). The Task Force for the
Diagnosis and Management of
Syncope of the European Society of
Cardiology (ESC)
• European Heart Rhythm Association (EHRA)
• Heart Failure Association (HFA)
• Heart Rhythm Society (HRS)
European Heart Journal 30, 2631-2671
G60 TRAUMA

7. G-60 Syncope Protocol
Initial Evaluation:
Determine medications
that effect initial evaluation
and care.
Consider common, acute,
non-traumatic events that
could complicate the
patient’s presentation
including:
….. SYNCOPE
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8. G-60 Syncope Protocol
Syncope
Transient and abrupt loss of
consciousness with complete return
to pre-existing neurological function.
… usually leading to falling
G60 TRAUMA

9. G-60 Syncope Protocol
Evaluation ---
Risk Stratification
• Risk of re-occurrence
• Risk of physical injury
• Risk of life threatening event
• Risk of death
G60 TRAUMA

10. G-60 Syncope Protocol
Why Develop Syncope
Protocol
• Determine if admission needed
(non-related to traumatic injuries)
• Initiate testing /consults from trauma bay
• Multidisciplinary team aware of protocol
• Avoid inappropriate, “shot gun”
approach—decreases overuse of
resources and decreases cost
• Facilitate patient progression
• Trauma Program Quality Improvement
G60 TRAUMA

11. G-60 Syncope ProtocolG60 TRAUMA
Syncope Evaluation
Obtain: History/ Physical
Order: 12 Lead ECG
Orthostatic Blood Pressure check
Labs: CBC and BMP
Trauma Care Pathway
Routine Orders by Trauma surgeon based
on Medical History, Mechanism of Injury
and Trauma Assessment
Non-Syncopal Event
· Intoxication
· Seizure
· Transient altered level of
consciousness
· TIA/ CVA
· Mechanical Fall
· Psychiatric
STOP- syncope eval
Non-Cardiac / Low Risk
Per assessment likely non-cardiac
· No history of heart disease
· Syncope related to nausea, emesis,
meals/hypoglycemia
· Positive Orthostatics (BP)
· Stress or Known recurrent syncope
· Common Medication side effect: ie: alpha
blocker, BB, diuretics
· Associated with Parkinson’s/ autonomic
dysreflexia
High /Cardiac Risk
Per Assessment likely cardiac source
· Abnormal ECG (see #1)
· Family history of sudden cardiac death
· Syncope with exertion or when supine
· Syncope with palpitations
· Presence of Pacemaker
· CAD and / or CHF
( 1) ECG -- 2 or 3
rd
degree HB, MI, previous MI, Q waves present, QT prolonged, LBBB, RBBB, HR < 50, VTach, non-sustained VT
(2) Diagnostic = severe Aortic sclerosis, HOCM, Tumor, tamponade, dissection
AHA/ ACCG Scientific Statement of Evaluation of Syncope (2006), AHRQ Guidelines for the diagnosis and management
of syncope (2009 version). UpToDate (accessed
1. Admit to observation-telemetry status (unless
trauma status dictates full admission)
2. Consultation Cardiology
3. Echocardiogram (see #2)
4. If applicable: interrogate Pacemaker
If above testing normal: ---- STOP
transition to Outpatient evaluation options
· Follow up with cardiologist: possible Holter
monitor, Loop Recorder, Event Monitor, Tilt table
· Neurological evaluation
· Psychiatric evaluation
Syncope Non-Syncope

12. G-60 Syncope Protocol
Trauma Care Pathway
Routine orders by Trauma surgeon based
on Medical History, Mechanism of Injury
and Trauma Assessment
Syncope Evaluation
Obtain: History/ Physical
Orthostatic Blood Pressure check
Order: 12 Lead EGC, CBC and BMP
G60 TRAUMA

13. G-60 Syncope Protocol
History and Physical
Most important tool in syncope evaluation
AHA/ACCF Scientific Statement
• 14% Dx based by H&P
• 10% Dx based on ECG
• 1% Dx based on Echocardiogram
After safety of patient—2nd goal syncope
evaluation is to determine if cause can be ID’d
and then treated.
G60 TRAUMA

14. G-60 Syncope Protocol
H&P in syncope evaluation
• Precipitating events
• Prodome
• Patient Position-
• Post Syncope exam/events
• Pre-existing Conditions
Differentiate types/ causes of syncopal
events and differential dx of presentations
similar to syncope: seizures, metabolic
disorders, acute intoxication or psychogenic
disorders
G60 TRAUMA

15. G-60 Syncope ProtocolG60 TRAUMA
Syncope Evaluation
Obtain: History/ Physical
Order: 12 Lead ECG
Orthostatic Blood Pressure check
Labs: CBC and BMP
Trauma Care Pathway
Routine Orders by Trauma surgeon based
on Medical History, Mechanism of Injury
and Trauma Assessment
Non-Syncopal Event
· Intoxication
· Seizure
· Transient altered level of
consciousness
· TIA/ CVA
· Mechanical Fall
· Psychiatric
STOP- syncope eval
Non-Cardiac / Low Risk
Per assessment likely non-cardiac
· No history of heart disease
· Syncope related to nausea, emesis,
meals/hypoglycemia
· Positive Orthostatics (BP)
· Stress or Known recurrent syncope
· Common Medication side effect: ie: alpha
blocker, BB, diuretics
· Associated with Parkinson’s/ autonomic
dysreflexia
High /Cardiac Risk
Per Assessment likely cardiac source
· Abnormal ECG (see #1)
· Family history of sudden cardiac death
· Syncope with exertion or when supine
· Syncope with palpitations
· Presence of Pacemaker
· CAD and / or CHF
( 1) ECG -- 2 or 3
rd
degree HB, MI, previous MI, Q waves present, QT prolonged, LBBB, RBBB, HR < 50, VTach, non-sustained VT
(2) Diagnostic = severe Aortic sclerosis, HOCM, Tumor, tamponade, dissection
AHA/ ACCG Scientific Statement of Evaluation of Syncope (2006), AHRQ Guidelines for the diagnosis and management
of syncope (2009 version). UpToDate (accessed
1. Admit to observation-telemetry status (unless
trauma status dictates full admission)
2. Consultation Cardiology
3. Echocardiogram (see #2)
4. If applicable: interrogate Pacemaker
If above testing normal: ---- STOP
transition to Outpatient evaluation options
· Follow up with cardiologist: possible Holter
monitor, Loop Recorder, Event Monitor, Tilt table
· Neurological evaluation
· Psychiatric evaluation
Syncope Non-Syncope

16. G-60 Syncope Protocol
High / Cardiac Risk
• Abnormal ECG-
2nd or 3rd Degree HB, MI, previous MI, Q waves present,
prolonged QT, LBBB, RBBB, HR < 50, Ventricular
tachycardia (VT), non-sustained VT
• Family Hx of sudden cardiac death
• Syncope with exertion or when
supine
• Syncope with palpitations
• Presence of pacemaker
• History of CAD and/ or CHF
G60 TRAUMA

17. G-60 Syncope Protocol
High / Cardiac Risk
• Admit to observation/ telemetry status.
(Unless trauma status dictates full
admission)
• Cardiology consultation
• Echocardiogram—severe aortic
stenosis, HOCM, Tumor, Tamponade,
dissection.
• If applicable: interrogate pacemaker
G60 TRAUMA

18. G-60 Syncope Protocol
High / Cardiac Risk
If testing normal—
STOP syncope evaluation
Transition to outpatient evaluations
• Possible outpatient cardiology
evaluation—Holter, Loop recorder,
event monitor, Tilt table
• Neurology
• Psychiatric
G60 TRAUMA

19. G-60 Syncope Protocol
Non-Cardiac/ Low Risk
Per assessment likely non-cardiac
• No history of heart disease
• Syncope related to nausea, emesis,
meals/ hypoglycemia
• Stress or known recurrent syncope
• Common medications—side effects ie:
alpha blockers, BB, CCB, diuretics
• Associated with Parkinson’s Disease
or Autonomic dysreflexia.
G60 TRAUMA

20. G-60 Syncope Protocol
Non-Syncopal Event
• Intoxication
• Seizures
• TIA/CVA
• Mechanical Fall
• Psychiatric “event”
STOP SYNCOPE EVALUATION
G60 TRAUMA

21. G-60 Syncope Protocol
What’s next:
• Evaluation of protocol effectiveness
• Individualized assessment—
Not all falls = syncope
• Continued multi-disciplinary approach
to assessment and planning
G60 TRAUMA

22. G-60 Syncope Protocol
ACS TQIP Geriatric Trauma Management Guidelines. American College of Surgeons Trauma Improvement Program
(ACS TQIP) Best Practices Guidelines. (2013)
Guidelines for the diagnosis and management of syncope (version 2009). The Task Force for the Diagnosis and
Management of Syncope of the European Society of Cardiology (ESC). Developed in collaboration with, European
Heart Rhythm Association (EHRA), Heart Failure Association (HFA) and Heart Rhythm Society (HRS). European
Heart Journal 30, 2631-2671.
Quinn,J, McDermott, Stiell,I et al (2004). Derivation of the San Francisco Syncope Rule to predict patients with short-
term serious outcomes. Annals of Emergency Medicine Feb. 43 (2):224-232
Reed, M, Coull, A, Jacques, K. (2010). The ROSE (Risk Stratification of syncope in emergency department) study.
Journal of the American College of Cardiology 55(8), 713-721.
Shen, W., Decker, W., Smars, P. et al (2004). Syncope Evaluation in the Emergency Department Study (SEEDS). A
Multidisciplinary approach to syncope management. Circulation 110: 3636-3645.
Strickberger, S., Benson, D., Biaggioni, I et al (2006). AHA/ ACCF Scientific Statement of the Evaluation of Syncope:
From the American Heart Association Councils on Clinical Cardiology, Cardiovascular Nursing, Cardiovascular
Disease in the Young, and Stroke, and the Quality of Care and Outcomes Research Interdisciplinary Working Group;
and the America College of Cardiology Foundation: In Collaboration With the Heart Rhythm Society: Endorsed by the
American Autonomic Society. Circulation, 113: 316-327.
G60 TRAUMA