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
