Lightning Rounds: Syncope

Appropriate Syncope Workup

• ​EKG
• Electrolytes: Not predictive of poor outcomes, and should not be part of your workup without a clinical suspicion.  
• Head CT: Only useful in those with neurologic deficits or focal symptoms during the syncopal episode, or those with trauma. ACEP Choosing Wisely. 
• CBC:  Anemia is predictive of poor outcomes, and patients should be evaluated if at risk for anemia (elderly, females with heavy menses, GI bleeds, or a concerning history). Utilized in the San Francisco Syncope Rule. 

EKG Abnormalities in Syncope

• Tachyarrhythmias
• Bifascicular block or conduction delay
• Bradycardia/AV block
• Prolonged or shortened QT interval
• Brugada pattern (RBBB with ST elevation)
• WPW
• Hypertrophic cardiomyopathy: sharp, deep Q waves in lateral leads, 
• Ischemia
• ARVD: Epsilon wave or negative T waves in precordial leads: Right sided cardiomyopathy, Typically presenting in young patients with a history of syncope. 

Epsilon Wave

Disposition of Syncopal Patients

ACEP Risk Factors in Syncope

• Suspected or diagnosed cardiac cause of syncope
  • Abnormal EKG
  • History or cardiac disease (CHF, low EF, new murmur)
  • Exertional Syncope
  • Sudden onset without a prodrome
• Anemia or other lab abnormalities
• ACEP Clinical Policy for Syncope Management

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