Syncope Treatment & Management

  • Author: Rumm Morag, MD, FACEP; Chief Editor: David FM Brown, MD   more...
 
Updated: Aug 11, 2011
 

Prehospital Care

Prehospital management of syncope covers a wide spectrum of acute care and includes rapid assessment of airway, breathing, circulation, and neurologic status.

Treatment may require the following:

  • Intravenous access
  • Oxygen administration
  • Advanced airway techniques
  • Glucose administration
  • Pharmacologic circulatory support
  • Pharmacologic or mechanical restraints
  • Defibrillation or temporary pacing

Advanced triage decisions, such as direct transport to multispecialty tertiary care centers, may be required in select cases.

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Emergency Department Care

In patients brought to the ED with a presumptive diagnosis of syncope, appropriate initial interventions include intravenous access, oxygen administration, and cardiac monitoring. ECG and rapid blood glucose evaluation should be promptly performed. A study to determine the sensitivity and specificity of the San Francisco Syncope Rule (SFSR) ECG criteria for determining cardiac outcomes found that when used correctly, the criteria can help predict which syncope patients are at risk of cardiac outcomes. ECG criteria predicted 36 of 42 patients with cardiac outcomes, with a sensitivity of 86%, a specificity of 70%, and a negative predictive value of 99%.[24]

Syncope may be the manifestation of an acute life-threatening process but is generally not emergent. Clinically ruling out certain processes is important. The treatment choice for syncope depends on the cause or precipitant of the syncope. Patients in whom a cause cannot be ascertained in the ED, especially if they have experienced significant trauma, warrant supportive care and monitoring.

Situational syncope treatment focuses on educating patients about the condition. For example, in carotid sinus syncope, patients should be instructed not to wear tight collars, to use a razor rather than electric shaver, and to maintain good hydration status; they should also be informed of the possibility of pacemaker placement in the future.

Orthostatic syncope treatment also focuses on educating the patient. Inform patients about avoiding postprandial dips in BP, teach them to elevate the head of their bed to prevent rapid BP fluctuations on arising from bed, and emphasize the importance of assuming an upright posture slowly. Additional therapy may include thromboembolic disease (TED) stockings, mineralocorticoids (eg, fludrocortisone for volume expansion), and other drugs such as midodrine (an alpha1-agonist with vasopressor activity). Patients' medications must be reviewed carefully to eliminate drugs associated with hypotension. Intentional oral fluid consumption is useful in decreasing frequency and severity of symptoms in these patients.

Cardiac arrhythmic syncope is treated with antiarrhythmic drugs or pacemaker placement. Consider cardiologist evaluation or inpatient management since this is more commonly associated with poor outcomes.[17] Trials assessing beta-blockade to prevent syncope have conflicting results, but no clear effect has been demonstrated.

Cardiac mechanical syncope may be treated with beta-blockade to decrease outflow obstruction and myocardial workload. Valvular disease may require surgical correction. This, too, is associated with increased future morbidity and mortality.

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Consultations

The etiology of syncope dictates the need, if any, for specialty consultation. Select cases may require consultation with a neurosurgeon, a neurologist, a cardiologist, a vascular surgeon, a cardiothoracic surgeon, an endocrinologist, or a toxicologist.

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Contributor Information and Disclosures
Author

Rumm Morag, MD, FACEP  Member of Salem Emergency Physician Services, PC (SEPS), Salem Hospital

Rumm Morag, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Barry E Brenner, MD, PhD, FACEP  Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

David A Peak, MD  Assistant Residency Director of Harvard Affiliated Emergency Medicine Residency, Attending Physician, Massachusetts General Hospital; Consulting Staff, Department of Hyperbaric Medicine, Massachusetts Eye and Ear Infirmary

David A Peak, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine, and Undersea and Hyperbaric Medical Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Eddy S Lang, MDCM, CCFP(EM), CSPQ  Associate Professor, Senior Researcher, Division of Emergency Medicine, Department of Family Medicine, University of Calgary Faculty of Medicine; Assistant Professor, Department of Family Medicine, McGill University Faculty of Medicine, Canada

Eddy S Lang, MDCM, CCFP(EM), CSPQ is a member of the following medical societies: American College of Emergency Physicians, Canadian Association of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

David FM Brown, MD  Associate Professor, Division of Emergency Medicine, Harvard Medical School; Vice Chair, Department of Emergency Medicine, Massachusetts General Hospital

David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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