Syncope

It’s not the faint — it’s what caused it.

Open full pathway

Educational first-pass aid. Reassess the patient, confirm doses and use local protocols.

1 · First minutes

ECG for everyone.
History for the cause: prodrome, posture, exertion, no warning.
Exclude bleed, PE, and ectopic when the story fits.

2 · Escalate now if

Exertional syncope or syncope while supine
No prodrome / sudden collapse with facial injury
Abnormal ECG (QTc >480 ms per CSRS; blocks, pre-excitation, Brugada, ischemia)
Structural heart disease or family history of sudden death
Chest pain, dyspnea, or palpitations preceding the event
Ongoing blood loss or positive hCG

3 · Immediate workup

12-lead ECG for everyone — QTc, blocks, delta waves, Brugada, ischemia, QRS axis/duration
Glucose; POCUS: RV strain, effusion, AAA, IVC

4 · Don’t miss

Lethal arrhythmia (long QT, WPW, Brugada, advanced block, VT)
Abnormal ECG, exertional or supine syncope, no prodrome, family history of sudden death.
Severe aortic stenosis / HCM
Exertional syncope with a pathologic murmur — echo.
High-risk PE
Syncope can be the only symptom; check VTE risks and RV strain.
Internal hemorrhage (AAA, GI bleed, ectopic)
Syncope with anemia, abdominal/back pain, or positive hCG.
SAH and other intracranial causes
Headache + collapse; “syncope with head injury” may be the other way around.

5 · Disposition lane

Admit (telemetry) or shared decision

CSRS +1 to +3 (medium, ~8% 30-day serious outcomes): shared decision / brief observation. Abnormal ECG not clearly chronic; frail elderly living alone.

ICU / expedited cardiac workup

CSRS ≥4, documented arrhythmia, exertional syncope with murmur, PE with shock or strain plus biomarkers, positive troponin with ischemic features.