Patients with syncope typically present with a transient loss of consciousness, which can have a broad spectrum of causes. Here, Professor Martin Möckel, of the EUSEM syncope group, summarises how group’s new European consensus provides detailed, process-driven guidance on managing and caring for patients with suspected syncope in the emergency setting.
Transient loss of consciousness (TLOC) is a brief period of unconsciousness followed by a complete recovery. Loss of consciousness can result from a variety of reasons, including traumatic and non-traumatic causes.
Syncope, which is defined as a decrease in blood pressure with a subsequent global cerebral hypoperfusion and loss of postural tone, is a subset of TLOC. It is a major healthcare issue, as approximately half of the population will likely experience at least one syncope episode during their lifetime.1
Early syncope guidelines
Patients with syncope represent approximately 1–5% of patients visiting the emergency department (ED).2
In 2018, the European Society of Cardiology (ESC) published guidelines for the diagnosis and management of syncope, which, for the first time, explicitly addressed management in the ED.2
The ESC guidelines2 proposed three risk categories: low-risk, neither high- nor low-risk and high-risk. These are important for determining how treatment should proceed after an initial assessment in the ED. Whereas low-risk patients can be discharged into outpatient care, high-risk patients require careful monitoring and admission to hospital.
Establishing a consensus for syncope care
Recently, a European prospective cohort study quantified that 75.3% of syncope patients in European EDs were at high risk and required further work-up.3 The European Society for Emergency Medicine (EUSEM) syncope group, therefore, aimed to establish a consensus to create a universal core process for diagnosing syncope, risk stratification and its initial management in the ED.
The group assessed current clinical practices in different European countries through literature searches. A modified three-step Delphi process was then used and a universal core process map for syncope management in European EDs was subsequently modelled.4
The map allows regional specifications due to different healthcare systems while ensuring that all critical steps from admission to diagnosis are carried out and that no high-risk situation is overlooked.
Syncope care steps
From an emergency medicine perspective, the care process starts with the patient who has presented with a TLOC. Thus, the first step after triage is to determine non-syncopal causes of the TLOC such as seizures, head trauma or physical shock.
Then, a systematic work-up is suggested to determine vital parameters including blood pressure, heart rate, oxygen saturation, temperature and respiratory rate; history; physical examination; ECG; and lab tests, with haemoglobin and blood glucose being the minimum.
At this stage, syncope as a symptom of an underlying cause (e.g. aortic valve stenosis) or as part of an acute disease-like infection is determined and the patient is referred to a care pathway for the principal disease as appropriate.
The ESC guideline criteria are used to stratify any remaining unexplained syncopes and patients are scheduled for further ambulatory care (low risk only), monitoring or hospital care, mainly to determine cardiac syncope or other rare causes of TLOC. The core process diagram included in the consensus allows European EDs to create regional digital flow charts.
When is further attention required?
Most TLOC presentations can be clarified by following the pathway. However, certain specific situations need special attention.
- Non-cardiac syncope with severe injuries
These patients may not have typical high-risk criteria but present with injuries due to reflex or orthostatic syncopes with nearly no prodromes. These patients need specialist care and individual therapeutic regimens. They should be admitted or sent to dedicated syncope units.
- Older patients with dementia
Older patients with dementia and no observed TLOC may have syncope even though a geriatric fall might be suspected. A thorough cardiovascular evaluation is recommended in these patients, who almost always present with high-risk features and comorbidities. Measurement of cardiovascular markers such as copeptin could help determine or rule out true syncope.
- Possible transient coma
Transient coma is a major challenge in the emergency setting. It is associated with high mortality and is usually a result of severe underlying pathologies. It must not be confused with syncope in the ED.5
Conclusion
The spectrum of syncope patients presenting with TLOC in the ED can be broad.
In the ED, the challenge is to determine cardiac syncope, geriatric falls or other diagnoses as the cause in this heterogeneous group of patients because it has been determined that three-quarters of patients have high-risk features and need urgent further hospital-based monitoring and subsequent work-up.
The 2018 ESC guidelines included recommendations for managing syncope in the ED but lacked detailed instructions on patient management. The EUSEM consensus aids informed decision-making regarding risk stratification, ruling out life-threatening causes and distinguishing syncopal and non-syncopal causes of loss of consciousness to achieve efficient and optimal patient care.
Author
Martin Möckel MD PhD FESC FAHA
Charité – University Medicine Berlin, Germany
References
- Brignole M et al; ESC Scientific Document Group. Practical Instructions for the 2018 ESC Guidelines for the diagnosis and management of syncope. Eur Heart J 2018;39(21):e43–e80.
- Brignole M et al; ESC Scientific Document Group. 2018 ESC Guidelines for the diagnosis and management of syncope. Eur Heart J 2018;39(21):1883–948.
- Reed MJ et al; SEED Investigators. Management of syncope in the Emergency Department: a European prospective cohort study (SEED). Eur J Emerg Med 2024;31(2):136–46.
- Möckel M et al; EUSEM syncope group. The syncope core management process in the emergency department: a consensus statement of the EUSEM syncope group. Eur J Emerg Med 2024;31(4):250–9.
- Lutz M et al. The accuracy of initial diagnoses in coma: an observational study in 835 patients with non-traumatic disorder of consciousness. Scand J Trauma Resusc Emerg Med 2021;29(1):15.
