Notes – Adult and Pediatric Syncope and Presyncope

Adult and Pediatric Syncope and Presyncope

Patient Safety Considerations:

  1. Patients suffering syncope due to arrhythmia may suffer recurrent arrhythmia and should therefore be placed on a cardiac monitor
  2. Geriatric patients suffering falls from standing may sustain significant injury and should be diligently screened for trauma – go to General Trauma Management guideline

Notes/Educational Pearls

Key Considerations

  1. By being most proximate to the scene and to the patient’s presentation, EMS providers are commonly in a unique position to identify the cause of syncope. Consideration of potential causes, ongoing monitoring of vitals and cardiac rhythm as well as detailed exam and history are essential pieces of information to pass onto hospital providers.
  2. All patients suffering from syncope deserve hospital level evaluation, even if they appear normal with few complaints on scene
  3. High risk causes of syncope include the following:
    1. Cardiovascular
      1. Myocardial infarction
      2. Aortic stenosis
      3. Hypertrophic cardiomyopathy
      4. Pulmonary embolus
      5. Thoracic aortic dissection
      6. Lethal dysrhythmia
    2.  Neurovascular
      1. Intracranial hemorrhage
      2. Transient ischemic attack or stroke
  4. Consider high risk 12-lead EKG features including, but not limited to:
    1. Evidence of QT prolongation (generally over 500ms)
    2. Delta waves
    3. Brugada syndrome (incomplete RBBB pattern in V1/V2 with ST segment elevation)
    4. Hypertrophic obstructive cardiomyopathy

Pertinent Assessment Findings

  1. Evidence of trauma
  2. Evidence of cardiac dysfunction (e.g. evidence of CHF, arrhythmia)
  3. Evidence of hemorrhage
  4. Evidence of neurologic compromise
  5. Evidence of alternate etiology, including seizure
  6. Initial and ongoing cardiac rhythm
  7. 12-lead EKG findings

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01)

  • 9914149 – Medical-Syncope

Key Documentation Elements

  • Presenting cardiac rhythm
  • Cardiac rhythm present when patient is symptomatic
  • Any cardiac rhythm changes

Performance Measures

  • Acquisition of 12-lead EKG
  • Application of cardiac monitor
  • EMS Compass® Measure (for additional information, see http://www.emscompass.org)
    • Stroke-01: Suspected stroke receiving prehospital stroke assessment. To measure the percentage of suspected stroke patients who had a stroke assessment performed by EMS

References

  1. Anderson JB, Willis M, Lancaster H, Leonard K, Thomas C. The evaluation and management of pediatric syncope. Pediatr Neurol. 2016;55:6-13.
  2. Benditt DG, Adkisson WO. Approach to the patient with syncope. Cardiol Clin. 2013;31(1):9-25.
  3. Dovgalyuk J, Holstege C, Mattu A, Brady WJ. The electrocardiogram in the patient with syncope. Am J Emerg Med. 2007;25:688-701.
  4. Fischer J, Choo CS. Pediatric syncope: cases from the emergency department. Emerg Med Clin North Am. 2010;28(3):501-16.
  5. Herbert M, Spangler M, Swadron S, Mason J. Emergency Medicine Reviews and Perspectives (EM:RAP). C3 Continuous Core Content Podcast. Syncope – Introduction. November 2016. https://www.emrap.org/episode/c3syncope/syncope. Accessed August 28, 2017.
  6. Huff JS, Decker WW, Quinn JV, Perron AD, Napoli AM, Peeters S, et al; American College of Emergency Physicians. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with syncope. Ann Emerg Med. 2007;49(4):431-44.
  7. Kessler C, Tristan JM, De Lorenzo R. The emergency department approach to syncope: evidence-based guidelines and prediction rules. Emerg Med Clin North Am. 2010;28(3):248-500.
  8. Khoo C, Chakrabarti S, Arbour L, Krahn AD. Recognizing life-threatening causes of syncope. Cardiol Clin. 2013;31(1):51-66.
  9. Orman R, Mattu A; Emergency Medicine Reviews and Perspectives (EMRAP). Spring Forward into PE. Cardiology Corner – Syncope. March 2016. https://www.emrap.org/episode/springforward/cardiology. Accessed August 28, 2017.
  10. Ouyang H, Quinn J. Diagnosis and management of syncope in the emergency department. Emerg Med Clin North Am. 2010;28(3):471.485.