Syncope in the Field

Why this matters

The patient is talking, embarrassed, and wants to sign a refusal. Some of those patients have complete heart block, gastrointestinal bleeding, a ruptured aortic aneurysm, an ectopic pregnancy, or a pulmonary embolism. Syncope is a brief loss of consciousness with spontaneous recovery. First, run a high-risk screen. Check the heart, bleeding, stroke, and glucose. Do not spend 40 minutes on a neurology consult, and do not clear a high-risk faint on the curb.

High-Risk Themes

• Cardiac: fainting during exertion, chest pain, palpitations, sudden death in the family, or an abnormal 12-lead. That includes blocks, a Brugada pattern, a long QT, ischemia, and Wolff-Parkinson-White. Heart-failure history also counts.
• Bleeding or low volume: blood from the gut, black stools, aortic aneurysm with back or flank pain, pregnancy with possible ectopic, and trauma.
• Neurologic: one-sided deficits, a worst headache, or features of a seizure. That may not be a simple faint.
• Check for low or high glucose, and for toxicology clues.

Clinical sequence

1. Protect the airway, breathing, and circulation. Use spinal motion restriction if they hit their head and meet your criteria.
2. Check glucose. Get a 12-lead. Do orthostatic vital signs only if your protocol uses them and it is safe for them to stand. They do not replace an ECG.
3. Take the history: warning symptoms, position, exertion, witnesses, incontinence, how they looked, and medicines such as beta-blockers, diuretics, and antiarrhythmics.
4. Hospital syncope scores, such as the San Francisco and Canadian scores, are emergency-department tools. They do not clear someone on the curb. If the 12-lead, the glucose, or the story is high-risk, they go to the hospital.
5. A refusal after high-risk syncope needs a capacity check and a call to medical control. Do not shrug it off.

Common errors

• Do not call exertional collapse vasovagal as the first label.
• Do not skip the 12-lead because they feel fine now.
• Do not miss pregnancy in a young patient who fainted and is hypotensive.

Practice

Related: 12-lead, AV blocks.

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 heart features (exertion, an abnormal ECG, or structural disease), bleeding, and neurologic features need an ECG, a glucose check, and transport. Do not make refusal the default.