Emergency Department Evaluation of the Syncopal Patient

This month is our July kickoff and we welcome our new PGY-1’s, PA fellows, EM destined medical students and new EPT staff. Without question, syncope and near-syncope are among the more common and challenging ED chief complaints with a host of etiologies. Up to 5% of these patients will have a “serious condition” after ED disposition and our risk tolerance remains very low, which explains high admission rates in the US. The challenge of accurate risk stratification has led to the development of a host of clinical decision tools which either, have not been or,  have failed external validation which is essential before the implementation of a clinical decision tool. This month , we will review a recently published validation study of the Canadian Syncope Risk Score and discuss applicability in our patient population. Interestingly, when compared to clinical gestalt, some decision tools (Well’s for PE) have not proven superior to clinical gestalt though I expect, some of our newbies might beg to differ. Identifying the etiology of syncope is rooted in an accurate history, exam and judicious testing which will be covered in the Rational Clinical Exam article and an article on ECG predictors in higher risk patients. An accurate H&P remains among the few level 1 recommendations on the ACC/AHA/HRS syncope guidelines and I will look forward to hearing some of our experts’ clinical pearls.  Finally, what may prove the most interesting article and is included in EVERY July JC, is an instructive article titled: Successful Hospitalization of Patients With no Discernible Pathology. We will strive to try to make JC not only informative but a fun, social activity, even virtually. Hopefully, we will someday soon be able to do so again in each other’s company.  

 Innes G, Successful hospitalization of patients with no discernible pathology. CJEM. 2000 Jan;2(1):47-51

Nishijima et al. ECG predictors of cardiac arrhythmias in older adults with syncope Ann Emerg Med. Ann Emerg Med. 2018 Apr; 71(4): 452–461 Appraisal

Albassam OT et al. Did This Patient Have Cardiac Syncope?: The Rational Clinical Examination Systematic Review. JAMA. 2019 Jun 25;321(24):2448-2457. Appraisal

Thiruganasambandamoorthy V et al. Multicenter Emergency Department Validation of the Canadian Syncope Risk Score.  JAMA Intern Med. 2020 Mar 23;180(5):1-8 Appraisal