From the Guidelines
No further action is required for this patient. The clinical presentation is consistent with a simple vasovagal syncope, which is a benign condition. The patient experienced typical prodromal symptoms including feeling warm, dizzy, hearing a rushing sound, and having darkening vision before a brief loss of consciousness. The episode lasted less than one minute with no concerning features such as tongue-biting or incontinence. Her vital signs are normal, with appropriate postural changes in blood pressure. Physical examination is normal, and the ECG shows normal sinus rhythm with no evidence of cardiac abnormalities. Given her young age, lack of personal or family medical history, normal examination findings, and the classic presentation of vasovagal syncope, additional investigations such as telemetry, chest x-ray, neurology referral, or echocardiogram would not be indicated, as supported by the American College of Radiology Appropriateness Criteria for syncope 1.
Key points to consider in this patient's management include:
- The patient's symptoms are consistent with vasovagal syncope, which is characterized by a reflex that causes vasodilation, bradycardia, or both, as defined by the 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope 1.
- The patient's age, lack of medical history, and normal examination findings make a cardiac or neurologic cause of syncope less likely, as discussed in the ACR Appropriateness Criteria for syncope 1.
- Patient education about avoiding triggers and recognizing prodromal symptoms would be appropriate, along with advice to maintain adequate hydration and to sit or lie down if similar symptoms recur.
- The ACR Appropriateness Criteria suggest that head CT and MRI should be avoided in uncomplicated syncope, and that additional testing should be limited to select patients based on clinical assessment 1.
From the Research
Evaluation of Syncope
The patient's presentation of syncope, characterized by a brief collapse, feeling warm and dizzy, a rushing sound, and darkening vision, suggests a transient loss of consciousness due to global cerebral hypoperfusion 2. The patient's normal physical examination, ECG, and vital signs indicate a low-risk profile.
Diagnostic Approach
The diagnostic approach to syncope involves a thorough history and physical examination, including orthostatic assessment 2. The patient's symptoms and normal examination results suggest a possible reflex syncope or orthostatic hypotension.
Testing and Monitoring
Studies have shown that routine testing, including echocardiography, telemetry, and ambulatory electrocardiography monitoring, has a relatively low diagnostic yield in patients with syncope 3. However, echocardiography may be useful in detecting cardiac abnormalities, particularly in patients with a moderate to high risk of cardiac syncope 4, 5.
Admission and Monitoring
The decision to admit the patient to a telemetry bed should be based on the patient's risk profile and the presence of underlying cardiac conditions 6. In this case, the patient's low-risk profile and normal examination results suggest that admission to a telemetry bed may not be necessary.
Next Steps
Based on the patient's presentation and low-risk profile, the following options are considered:
- No further action is required, as the patient's symptoms and examination results are consistent with a benign cause of syncope.
- Outpatient evaluation with tilt-table testing may be considered to further evaluate the patient's symptoms and determine the cause of syncope 2.
- Transthoracic echocardiogram may be considered if the patient's risk profile changes or if cardiac syncope is suspected 4, 5.