Physician gestalt garnered from the three-step approach outlined here should be used to identify low-risk patients who are safe for discharge from the ED. A thorough history and thoughtful but directed physical examination, rather than laboratory tests and imaging, should guide management. Syncope decision tools, laboratory testing, and imaging still have a role—lab tests and imaging should be used in patients suspected of a secondary vascular catastrophe as the cause of syncope and decision tools can be used to reassure physicians and patients.

A special thanks to Dr. David Carr, the guest expert on the EM Cases podcast from which this column was inspired.

Dr. Helman is an emergency physician at North York General Hospital in Toronto. He is an assistant professor at the University of Toronto, Division of Emergency Medicine, and the education innovation lead at the Schwartz/Reisman Emergency Medicine Institute. He is the founder and host of Emergency Medicine Cases podcast and website.

References

1. Yiadom MYAB, Napoli A, Granovsky M, et al. Managing and measuring emergency department care: results of the fourth Emergency Department Benchmarking Definitions Summit. Acad Emerg Med. 2020;27(7):600–611.
2. Goyal N, Donnino MW, Vachhani R, et al. The utility of head computed tomography in the emergency department evaluation of syncope. Intern Emerg Med. 2006;(1)148–150.
3. Giglio P, Bednarczyk EM, Weiss K, et al. Syncope and head CT scans in the emergency department. Emerg Radiol. 2005;12:44–46.
4. Grossman SA, Fischer C, Bar JL, et al. The yield of head CT in syncope: a pilot study. Intern Emerg Med. 2007;2:46–49
5. Huff JS, Decker WW, Quinn JV, 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.
6. Albassam OT, Redelmeier RJ, Shadowitz S, et al. Did this patient have cardiac syncope? JAMA. 2019;321(24):2448
7. Petkar S, Cooper P, Fitzpatrick AP. How to avoid a misdiagnosis in patients presenting with transient loss of consciousness. Postgrad Med J. 2006;82(972):630–41.
8. Benbadis SR, Wolgamuth BR, Goren H, et al. Value of tongue biting in the diagnosis of seizures. Arch Intern Med. 1995;155(21):2346–9.
9. Shmuely S, Bauer PR, van Zwet EW, et al. Differentiating motor phenomena in tilt-induced syncope and convulsive seizures. Neurology. 2018;90(15):e1339–e1346.
10. Saccomanno S, Greco F, DE Corso E, et a. Eagle’s syndrome, from clinical presentation to diagnosis and surgical treatment: a case report. Acta Otorhinolaryngol Ital. 2018;38(2):166–169.
11. Taniguchi T, Morimoto T, Shiomi H, et al. Sudden death in patients with severe aortic stenosis: observations from the current as registry. J Am Heart Assoc. 2018;7(11):e008397.
12. Williams L, Frenneaux M. Syncope in hypertrophic cardiomyopathy: mechanisms and consequences for treatment. Europace. 2007;9(9):817–22.
13. Sutton R. Syncope in patients with pacemakers. Arrhythm Electrophysiol Rev. 2015;4(3):189–92.
14. Arthur W, Kaye GC. Important points in the clinical evaluation of patients with syncope. Postgrad Med J. 2001;77(904):99–102.
15. Furtan S, Pochciał P, Timler D, et al. Prognosis of syncope with head injury: a tertiary center perspective. Front Cardiovasc Med. 2020;23(7):125
16. Mizrachi EM, Sitammagari KK. Cardiac Syncope. StatPearls [Internet]. http://bi.nlm.nih.gov/books/NBK526027/ Published January, 2022. Accessed December 23, 2022.
17. Koene RJ, Adkisson WO, Benditt DG. Syncope and the risk of sudden cardiac death: Evaluation, management, and prevention. J Arrhythm. 2017;33(6):533–544.
18. Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA Guideline for the management of patients with valvular heart disease: executive summary: a report of the American College Of Cardiology/American Heart Association joint committee on clinical practice guidelines. Circulation. 2021;143(5):e35–e71.
19. Goyal P, Maurer MS. Syncope in older adults. J Geriatr Cardiol. 2016;13(5):380-6.
20. White JL, Hollander JE, Chang AM, et al. Orthostatic vital signs do not predict 30 day serious outcomes in older emergency department patients with syncope: A multicenter observational study. Am J Emerg Med. 2019;37(12):2215–2223.
21. Kapoor WN. Current evaluation and management of syncope. Circulation. 2002;106(13):1606–9.
22. Sun BC et al. Predictors of 30-day serious events in older patients with syncope. Ann Emerg Med. 2009;54:769–778.
23. Thiruganasambandamoorthy V, et al. Outcomes in presyncope patients: a prospective cohort study. Ann Emerg Med. 2015;65:268–276.
24. Alboni P, Brignole M, Menozzi C, et al. Diagnostic value of history in patients with syncope with or without heart disease. J Am Coll Cardiol. 2001;37(7):1921–1928.
25. Quinn J, McDermott D, Stiell I, et al. Prospective validation of the San Francisco Syncope Rule to predict patients with serious outcomes. Ann Emerg Med. 2006;47(5):448–54.
26. Saccilotto RT, Nickel CH, Bucher HC, et al. San Francisco Syncope Rule to predict short-term serious outcomes: a systematic review. CMAJ. 2011;183(15):E1116–26.
27. Thiruganasambandamoorthy V, Kwong K, Wells GA, et al. development of the Canadian Syncope Risk Score to predict serious adverse events after emergency department assessment of syncope. CMAJ. 2016;188(12):E289–E298.
28. Thiruganasambandamoorthy V, Sivilotti MLA, Le Sage N, et al. multicenter emergency department validation of the Canadian Syncope Risk Score. JAMA Intern Med. 2020;180(5):737–744.
29. Solbiati M, Talerico G, Villa P, et al. Multicentre external validation of the Canadian Syncope Risk Score to predict adverse events and comparison with clinical judgement. Emergency Medicine Journal. 2021;38(9):701–706.