Syncope observation

Very common case of ER visit, Etiology is not clear in majority of the cases. Then comes Vasovagal and orthostatic syncope are also very commonly seen.

EMS:

IV line and IV Fluids

Blood sugar check

EKG

ER:

Routine labs, EKG, CXR, CT Head in some

Oxygen

IV Fluids

UA

Blood Cultures if infection suspected

Orthostatic Vitals (Orthostasis)-From lying position to standing position, there should be a drop in SBP of 20mm Hg, 10mm Hg drop in DBP and increase in pulse rate of around 15 (Request ED to do orthostatic vitals as lot of times it might have not been done by the time patient is signed out to you)

Hold offending medications based on possible etiology-Hold antihypertensive meds in cases of hypotension, Diabetic meds for hypoglycemia, Diuretics in cases of dehydration, etc.

Hospitalist:

History is very very important

Telemetry under observation

IV fluids-NS for hypotension

Compression Stockings for orthostatic hypotension

Rise from lying to sitting position and then standing position slowly

Patients need to be told to keep themselves well hydrated if no fluid issues due to CHF, or other conditions causing fluid overload.

Bed rest, Fall precautions, Bed alarms are placed by nursing staff

ECHO, EEG if seizure suspected, Carotid Doppler in selected cases

Consult Cardiology or Neurology or both depending on possible cause of the Syncope

Orthostatic Hypotension is a common finding-Fludrocortisone and/or Midodrine may be necessary

Tilt Table Test may be needed to rule out vasovagal syncope in a few selected cases as determined by cardiology.

Cardiology and Neurology may decide on more testing depending on the patient’s overall situation

Cardiology will arrange Holter monitor/ ZIO patch after patient goes home if no particular etiology was found. [ There are other tests like Event Recorder to be activated by the patient, Loop Recorder which continuously saves rhythm strip and Implantable Loop Recorder which can stay in place for up to 3 years.]

Patients may need to hold off on driving if having multiple episodes

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