What is the management approach for a patient experiencing syncope, described as a 'swimming' sensation, suggestive of a vasovagal (vagal nerve stimulation) episode?

From the Guidelines

For a patient with syncope at work described as "swimming-something," which suggests a vasovagal episode, the most appropriate immediate management is to have the patient lie down with legs elevated to restore cerebral blood flow, as recommended by the 2019 American Heart Association and American Red Cross guidelines for first aid 1. This approach is based on the understanding that vasovagal syncope results from decreased blood return to the heart, leading to decreased cardiac output and global cerebral perfusion, and that physical counterpressure maneuvers (PCMs) can help improve symptoms and prevent syncope. The patient should be kept in a safe position, such as sitting or lying down, and if possible, PCMs can be used to avoid syncope, with lower-body PCMs being preferable to upper-body and abdominal PCMs 1. Key considerations in management include:

• Ensuring the patient's safety to prevent injury from falls
• Assessing for any signs or symptoms that may indicate a more serious underlying cause of syncope, such as cardiac arrhythmias or structural heart disease
• Providing education on recognizing pre-syncope symptoms and taking preventive measures, such as avoiding trigger events and staying hydrated
• Referring the patient for medical evaluation to rule out cardiac causes of syncope, even if they feel completely recovered, as emphasized in guidelines from the European Heart Journal 1 and Annals of Emergency Medicine 1. It's also important to note that while various treatments have been proposed for vasovagal syncope, including medications like beta-blockers and vasoconstrictors, the evidence supporting their efficacy is limited, and they should be used with caution, as highlighted in the European Heart Journal guidelines 1. Overall, the management of vasovagal syncope should prioritize ensuring the patient's safety, providing education on preventive measures, and referring for medical evaluation to rule out more serious underlying causes.

From the Research

Initial Assessment

The patient's description of the event as "swimming-something" and the observation by a colleague suggests a possible vasovagal syncope scenario. The first step in evaluation is to:

• Take a thorough history of the event, including any potential triggers or preceding symptoms
• Perform a physical examination, including orthostatic blood pressure measurements
• Obtain an electrocardiogram (ECG) as part of the initial evaluation 2, 3

Classification of Syncope

Syncope can be classified into three primary categories:

• Cardiac syncope
• Reflex (neurogenic) syncope
• Orthostatic syncope The patient's symptoms and history will help determine which category is most likely 4, 5, 3

Risk Stratification

After initial evaluation, it is essential to perform short-term risk assessment to determine the need for admission:

• Patients with suspected cardiac syncope or those at higher risk of adverse outcomes may require inpatient evaluation 4, 5, 3
• Patients with suspected reflex syncope or orthostatic hypotension may be suitable for outpatient evaluation 5

Diagnostic Testing

Further diagnostic testing, such as:

• Prolonged electrocardiographic monitoring
• Stress testing
• Echocardiography may be beneficial in patients at higher risk of adverse outcomes from cardiac syncope 4, 2 However, laboratory tests and neuroimaging should only be ordered if clinically indicated, as they have a low diagnostic yield 3