What is the immediate management and treatment for a patient presenting with syncope?

Immediate Management of Syncope

Begin with a focused history, orthostatic vital signs, cardiovascular examination, and 12-lead ECG—this initial triad identifies the cause in up to 50% of cases and immediately stratifies risk for cardiac death. 1, 2, 3

Initial Assessment Components

History Taking (Highest Yield)

• Document the "3 Ps": Posture (prolonged standing), Provoking factors (pain, medical procedures), and Prodromal symptoms (sweating, warmth) to identify vasovagal syncope 1
• Obtain detailed circumstances: Position during event, activity level, specific triggers, witness account of the event, and recovery phase symptoms 1, 2
• Red flag features requiring immediate action: Syncope during exertion or supine position, chest pain, palpitations before the event, family history of sudden cardiac death, or brief/absent prodrome 1, 2

Physical Examination

• Measure orthostatic blood pressure in lying, sitting, and standing positions—a drop ≥20 mmHg systolic or to <90 mmHg defines orthostatic hypotension 1, 2
• Complete cardiovascular examination focusing on murmurs, gallops, rubs, and signs of heart failure that indicate structural heart disease 1, 2
• Carotid sinus massage in patients over 40 years old (when no carotid bruits present) to identify carotid sinus syndrome 1, 2

12-Lead ECG (Mandatory)

• Look for high-risk findings: Bifascicular block, prolonged QT interval, Brugada pattern, arrhythmogenic right ventricular cardiomyopathy pattern, severe bradycardia, or ischemic changes 1, 2

Risk Stratification and Disposition

Admit Immediately (High-Risk Features)

• History of heart failure or ventricular arrhythmias 1
• Chest pain or symptoms of acute coronary syndrome 1
• Abnormal ECG showing ischemia, arrhythmia, prolonged QT, or bundle branch block 1, 2
• Physical exam findings of significant heart failure or valvular disease 1
• Age >60 years with cardiac history or exertional syncope 1, 2
• Syncope during exertion or while supine (suggests arrhythmic cause) 2
• Structural heart disease on examination 2

Outpatient Management (Low-Risk Features)

• Younger age, no cardiac disease, normal ECG 2
• Syncope only when standing with clear positional triggers 2
• Prodromal symptoms (nausea, diaphoresis, warmth) suggesting vasovagal mechanism 1, 2
• Specific situational triggers (cough, micturition, defecation) 2

Immediate Treatment Based on Etiology

Vasovagal Syncope (Most Common)

• Reassure the patient once cardiac causes are excluded—this is often sufficient for single episodes 1, 4
• Increase salt and fluid intake to expand intravascular volume 4
• Teach physical counterpressure maneuvers: Leg crossing, hand grip, and arm tensing to abort prodromal symptoms 5, 6
• Avoid triggers: Prolonged standing, dehydration, hot environments 1, 4

Orthostatic Hypotension

• Review and discontinue offending medications: Diuretics, vasodilators, antihypertensives 2, 5
• Increase sodium and fluid intake 6, 7
• Instruct on postural changes: Rise slowly from supine to sitting to standing 6, 7
• Consider fludrocortisone or midodrine for refractory cases 7

Cardiac Syncope (Highest Mortality Risk)

• Admit for continuous telemetry monitoring 1, 2
• Urgent cardiology consultation for structural heart disease or arrhythmia 1, 2
• Treat underlying arrhythmia: Pacemaker for bradycardia, ablation or device therapy for tachyarrhythmias 1
• Echocardiography when structural disease suspected 1, 2

Targeted Testing (Only When Clinically Indicated)

Do NOT Order Routinely

• Comprehensive laboratory panels have extremely low yield without specific clinical suspicion 2
• Brain imaging (CT/MRI) has 0.24-1% diagnostic yield without focal neurological findings 2
• EEG has 0.7% yield without seizure features 2
• Carotid ultrasound has 0.5% yield without focal neurological deficits 2

Order Selectively Based on Clinical Suspicion

• Hematocrit if bleeding or anemia suspected (San Francisco Syncope Rule includes hematocrit <30%) 2
• Troponin and BNP only if acute coronary syndrome or heart failure suspected 2
• Echocardiography for abnormal cardiac exam, abnormal ECG, or suspected structural disease 1, 2
• Holter or event monitor for palpitations or suspected arrhythmia—select device based on symptom frequency 1, 2
• Exercise stress test for syncope during or after exertion 2
• Tilt-table testing for recurrent unexplained syncope in young patients without cardiac disease 1, 2

Common Pitfalls to Avoid

• Do not order "syncope workups" with comprehensive labs, brain imaging, and carotid ultrasounds without specific indications—this wastes resources and has minimal diagnostic yield 2
• Do not miss medication-induced syncope—review all medications, especially antihypertensives, diuretics, and vasodilators 2, 5
• Do not discharge high-risk patients (age >60, cardiac history, abnormal ECG, exertional syncope) without admission or urgent follow-up 1, 2
• Do not confuse brief seizure-like activity during syncope with epilepsy—brief myoclonic jerks can occur with any syncope from cerebral hypoperfusion 1
• Do not use short-term Holter monitors for infrequent symptoms—select longer monitoring (event recorder, implantable loop recorder) based on symptom frequency 1, 8

Key Prognostic Points

• Cardiac syncope carries 18-33% one-year mortality versus 3-4% for non-cardiac causes 1
• Recurrent syncope causes fractures in 12% of patients and significantly impairs quality of life 2
• Single episode of vasovagal syncope in young healthy patients requires no further testing after normal initial evaluation 1, 3