Syncope in the Field

Why This Is Hard

The patient is talking, embarrassed, and wants to sign off. Some of those patients have complete heart block, GI bleeding, ruptured AAA, ectopic pregnancy, or a PE. Syncope means transient loss of consciousness with spontaneous recovery. Your job is a high-risk screen, not a 40-minute neurology consult.

High-Risk Themes

• Cardiac: exertional syncope, chest pain, palpitations, family sudden death, abnormal 12-lead (blocks, Brugada-pattern teaching, long QT, ischemia, WPW), heart failure history.
• Bleed / volume: GI blood, black stools, AAA back/flank pain, pregnancy (ectopic), trauma.
• Neuro: focal deficits, worst headache, seizure features — may not be “simple faint.”
• Glucose and toxicologic clues.

EMS Priorities

1. ABCs, c-spine if they hit their head and meet SMR criteria.
2. Glucose. 12-lead. Orthostatics only if protocol uses them and they are safe to stand — not instead of an ECG.
3. History: prodrome, position, exertion, witnesses, incontinence, how they looked, meds (beta-blockers, diuretics, antiarrhythmics).
4. Refusals: high-risk syncope is a medical-control / capacity conversation, not a shrug.

Field Pitfalls

• “Vasovagal” as the first label in an exertional collapse.
• No 12-lead because they feel fine now.
• Missing pregnancy in a young hypotensive faint.

Practice

Sources & Further Study

Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.

• 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope
• NASEMSO National Model EMS Clinical Guidelines (2022)
• Syncope is a symptom. High-risk cardiac (exertional, abnormal ECG, structural disease), bleed, and neuro features need ECG, glucose, and transport — not a default refusal.