Current best practices in emergency evaluation and management of syncope

Abstract

The Nurse Practitioner • August 2021 25 yncope is a common complaint among patients seeking immediate medical care in a multitude of different settings. In the ED alone, syncope accounts for approximately 740,000 visits annually with up to 460,000 of these patients being admitted or placed in observation. [1][2][3] Syncope is defi ned as a transient loss of consciousness typically caused by decreased blood flow to the brain followed by complete recovery. 4,5 It is characterized by a rapid onset and a short duration. 6 Syncope itself often poses a challenging case for most hospital providers, as patients are typically asymptomatic upon presentation and have a rather low rate of etiologic diagnosis. Patients with syncope frequently undergo signifi cant diagnostic testing, often with minimal diagnostic yield and thus unclear benefi t. [7][8][9][10][11] Hospitalizations for syncope average about $5,300 per admission or $2.4 billion dollars annually in the US, and often fail to identify the etiology of the syncopal episode. 1,4,8,[11][12][13] ■ Clinical predictors for syncope Syncope can result from a number of different causes, including a vasovagal response, orthostatic hypotension, cardiac abnormalities, medication issues, neurologic ailments, or even idiopathic causes. 4,9 Most often, the cause of syncope is benign, self-limiting, and most commonly attributed to a vasovagal response or orthostatic hypotension. 5,6,9,12,14 It is essential to initially distinguish between true syncope and other causes of transient loss of consciousness such as seizures or traumatic causes including falls or concussions. Once this determination is made, the provider must further distinguish between benign causes and potentially worrisome conditions such as cardiac or neurologic syncope. 4,12,14 Most morbidity and mortality associated with syncope is related to cardiac causes. 12,14 Refl ex or neurally-mediated syncope is typically defi ned as syncope occurring in the absence of heart disease or trauma caused by exposure to an unpleasant circumstance. 12,15,16 Vasovagal syncope is the most common type of refl ex syncope and may occur in situations such as prolonged sitting or standing especially in hot or crowded places or following sudden exposure to pain or unpleasant sights, sounds, emotions, or smells. Refl ex syncope can also occur with head rotation or carotid sinus pressure due to tight collars, neck ties, or tumors, or after eating or

Counter pressure maneuvers for syncope prevention: A semi-systematic review and meta-analysis

“…While this group reports one of the highest success rates (97% recovered), their methods involve pseudo replication, and fail to account for any episodes of presyncope that would not have progressed into syncope even in the absence of deployment of CPM. With this cohort reporting a median of 3 (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11) syncopal episodes in the prior year, the majority of presyncopal episodes assessed would have presumably resolved spontaneously (67). For a clearer understanding of the efficacy of CPM in managing syncope symptoms, more rigorous and unbiased assessments including a placebo or control treatment are needed.…”

“…Syncope accounts for up to 2% of emergency department visits, of which 12–85% of patients are subsequently admitted to the hospital, with admission rates varying depending on the country and respective healthcare system considered ( 4 ). This presents a substantial healthcare burden, with an annual cost to the healthcare system of up to $2.4 billion annually in the United States ( 5 , 6 ).…”