EVALUATION OF SYNCOPE IN THE EMERGENCY DEPARTMENT
Section snippets
Etiology
The clinical evaluation of patients with sudden loss of consciousness must consider the pathophysiology of syncope and the vast array of underlying diagnoses that may present as syncope (Table 1).22, 33, 34, 37 The most common reported causes for syncope include the following, in descending order: undetermined cause, neurally mediated syncope, arrhythmia, neurologic causes (including seizure), orthostatic hypotension, and situational syncope.22
PATHOPHYSIOLOGY
Normal function of specific CNS structures (e.g., the reticular activating system, cerebral cortices), is required for the preservation of consciousness. Hypoperfusion of these structures may cause syncope. Such reductions of blood flow occur with transient systemic hypotension or with regional hypoperfusion, such as with vasoconstriction of cerebral arteries as in hyperventilation (resulting in hypocapnea) or interruptions by atherosclerotic processes.
Syncope can indicate underlying neurologic
EMERGENCY EVALUATION
Essential to the clinical evaluation of syncope in the ED is the determination of an accurate diagnosis, or a risk stratification of those patients without a firm diagnosis so that appropriate treatment decisions can be made. An appropriate history, physical examination, and limited diagnostic testing (e.g., ECG and rhythm monitoring) are sufficient to either establish the diagnosis or furnish sufficient information to determine whether further diagnostic testing or hospitalization is necessary
TREATMENT AND DISPOSITION
Treatment of syncope is directed at symptomatic support, modification or discontinuation of medications causing the loss of consciousness, management of the underlying disorder (e.g., use of pacemaker for third-degree AV block) and avoidance of activities in which syncope could endanger either the patient or others (e.g., swimming or driving a car). There are no standard guidelines for when a patient can resume all activities after a syncopal event, and emergency physicians should be aware of
CONCLUSION
In summary, when evaluating a patient with loss of consciousness, the emergency physician should differentiate syncope from other causes, such as seizure. Historical factors, as well as careful attention to the physical examination and the ECG are the most important elements to the initial assessment of the syncopal patient. The cause of the syncopal event is unexplained for many patients, and therefore the use of clinical guidelines for risk stratification helps to guide decisions on whether
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2002, Emergency Medicine Journal
Address reprint requests to Oliver W. Hayes, DO, FACEP, Section of Emergency Medicine, College of Osteopathic Medicine, B-305-C West Fee Hall, Michigan State University, East Lansing, MI 48824–1316
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Division of Emergency Medicine, Michigan State University, East Lansing, Michigan