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This article, based on the 2018 European Society of Cardiology syncope guidelines, highlights the key features of the management of syncope in the Emergency Department (ED) based on risk stratification. Firstly Transient Loss of Consciousness of a syncopal nature should be established. Secondly the treating clinician should ask whether syncope is the presenting feature of an obvious acute disease; if so, treatment and management should follow the guidelines of the specific complaint. If there is no obvious underlying cause, the treating clinician should assess the risk of a serious outcome aided by a risk stratification approach using history, past medical history, examination and ECG. Patients with low-risk characteristics are more likely to have reflex, situational or orthostatic syncope with generally an excellent prognosis and should likely be able to be discharged from the ED with education. Patients with high-risk characteristics are more likely to have cardiac syncope requiring urgent investigation and likely admission but alternatively may be able to be observed in an Observation or Syncope Unit. Patients with neither high nor low-risk features can probably be safely managed in an outpatient setting; there is evidence that management in an ED observation unit and/or fast track to a syncope clinic is beneficial. Risk stratification scores and clinical decision rules are yet to prove useful. There is little evidence that hospital admission in unexplained syncope is useful and novel organisational approaches such as ED observation units and syncope in- and outpatient units offer safe and effective alternatives to admission.
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