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Approach to syncope

The same eight steps, every presentation: threats first, then the history and exam that discriminate, one honest sentence, a mechanism-grouped differential, and the tests read in order.

  1. Immediate threats

    • Arrhythmic syncope: no warning, during exertion, or while supine
    • Outflow obstruction: aortic stenosis, HOCM, massive PE
    • Hemorrhage presenting as collapse: GI bleed, ruptured ectopic, AAA
    • The fall's own damage: head injury on anticoagulation

  2. History that discriminates

    • The three phases: what came before (prodrome), during (witness account), after (recovery speed)
    • Vasovagal signatures: trigger, warmth, nausea, gradual fade, rapid full recovery
    • Cardiac signatures: none of the above; exertional; palpitations first; family history of sudden death
    • Seizure discriminators: tongue biting, prolonged confusion after, tonic-clonic activity from onset

  3. Examination

    • Orthostatic vitals, properly done: after three minutes standing
    • Murmur of aortic stenosis or HOCM (louder with Valsalva)
    • Rectal exam and hemoglobin when bleeding is possible
    • Injury survey, especially head and hip

  4. Problem representation

    Exertional syncope without prodrome in an older patient with a systolic murmur (structural, urgent) versus a prodromal faint after standing in a hot queue with instant recovery (vasovagal, benign).

  5. Differential, by mechanism

    Reflex

    • Vasovagal
    • Situational (cough, micturition)
    • Carotid sinus hypersensitivity

    Orthostatic

    • Volume depletion
    • Medication-induced
    • Autonomic failure

    Cardiac

    • Bradyarrhythmia (blocks)
    • Tachyarrhythmia (VT)
    • Aortic stenosis
    • HOCM
    • PE

    Mimics

    • Seizure
    • Hypoglycemia
    • Psychogenic

  6. Investigations

    • ECG on everyone: intervals, blocks, pre-excitation, long QT
    • Orthostatic vitals and glucose
    • Hemoglobin when the story allows bleeding
    • Echocardiogram when there is a murmur or exertional story
    • Monitoring (telemetry to implantable recorder) scaled to arrhythmia suspicion

  7. Interpretation

    • The ECG's job is the intervals: PR, QRS, QT, and any block pattern
    • A structurally abnormal heart moves everything toward admission and monitoring
    • A perfect vasovagal story with a normal ECG rarely needs more than reassurance

  8. Next steps

    • Risk-stratify explicitly; admission is for the heart, not the faint
    • Fix the reversible: volume, offending antihypertensives, rate-limiting drugs

Connected

ECGComplete heart blockECGLong QTECGConduction disease in a fainter

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