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GUIDELINES UpDatE
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2 | Clinical for
PAGE 2|Guideline Policy:
the Critical December
December2010
PAGE
Issues In The
Management Evalua-
Of Acute Current
Current Guidelines
GuidelinesForForDiagnosis Volume
2009
Volume2,1,Number
Number122
tionChronic
And
Of
And Management
Adult
Pain In
Patients Pre-
Sickle Cell Disease.
And Management
Sickle Of Syncope In
Cell Disease:
Authors
Editor-In-Chief
Christopher R. Tainter, MD

The Emergency Department

Department of Emergency Medicine, Mount Sinai Hospital, New York, NY
sentingPain
To The Emer- Reuben J. Strayer, MD
American Society.
gency Department Management Of Acute Complications Assistant Professor of Emergency Medicine,
Editor-In-Chief

II
Mount Sinai School of Medicine, New York, NY
Reuben J. Strayer, MD
With Syncope n this issue of EM Practice Guidelines Update, 2 practice guidelines ad- Assistant Professor of Emergency Medicine, Mount Sinai School of Medicine,
In this issue of EM Practice Guidelines Update, 2 guidelines Editorial Board
dressing the management of syncope are reviewed. Syncope is a brief, New York, NY
PAGE 4 | The Management
Annals of Medicine
of Emergency Sickle addressing
transient theconsciousness
loss of management of sickle cell
accompanied disease
by loss (SCD)
of postural are
tone, Andy Jagoda, MD, FACEP
Editorial Board
Professor and Chair, Department of Emergency Medicine
Cell Disease. National withreviewed.
spontaneous As recovery.
a result Itofisnumerous
attributed toSCD-related
global cerebralcomplications,
hypoperfusion, Nicole
MountC. Bouchard,
Sinai School ofMD, FRCPCNew York, NY
Medicine,
PAGE 4|Institutes of Health,
For National
Assistant Clinical Professor, Assistant Site Director; Director of Medical Toxicology,
Guidelines The distinct
patients from other
with SCD possible
havecauses of altered
significantly consciousness
diminished such as seizure
life expectancy. Erik
New Kulstad, MD,
York-Presbyterian MSColumbia University Medical Center, New York, NY
Hospital,
Heart Lung and Blood
Diagnosis And Man- or trauma. It is estimated to account for 1% to 1.5%
Although most patients will be followed by subspecialty of annual emergency
hema-
Research Director, Advocate Christ Medical Center
Andy Jagoda,
Department ofMD, FACEP Medicine, Oak Lawn, IL
Emergency
Institute.
agement Of Syncope department (ED) visits, and up to 6% of admissions. 1
tologists, SCD is fundamentally a “‘disease of emergencies.”’ Professor and Chair, Department of Emergency Medicine, Mount Sinai School of
Eddy S.
Medicine, NewLang,
York, NYMDCM, CCFP (EM), CSPQ
(Version 2009) Emergency
The prevalence clinicians
of syncope,should
thoughbenotfamiliar with the
well-reported, recommenda-
is high, on the order Associate Professor, McGill University, SMBD Jewish General
Erik Kulstad,
Hospital, MD, MS
Montreal, Canada
tions
of around
6.2-9.3 management
per 1000 person-years.of2,3acute SCD
Though thecomplications,
cause of syncopebecause
is often Research Director, Department of Emergency Medicine, Advocate Christ
LewisCenter,
Medical S. Nelson,
Oak Lawn,MDIL
European Heart Journal benign or unexplained, 2
a significant number of patients presenting
failure to appreciate the nuances of care in these brittle patients to the Director, Fellowship in Medical Toxicology, New York City Poison
Eddy S. Lang, MDCM, CCFP (EM), CSPQ
Control Center, Associate Professor, Department of Emergency
emergency department (ED) with syncope have a potentially
may place them at risk for short-term morbidity and mortality. The dangerous un- Senior Researcher, Alberta Health Services; Associate Professor, University of
Medicine, NYU Medical Center, New York, NY
PAGE 6| Editorial Comment derlying etiology, most of which have specific therapies. Syncope is therefore Calgary; Adjunct Professor, McGill University, Montreal, Quebec, Canada
methodology of these practice guidelines varies greatly–from Gregory
Lewis M. Press,
S. Nelson, MD MD, RDMS
aevidence-
cardinal, high-risk
based presentation for the emergency
to expert opinion–and clinician.
thus must be Because
applied theto Assistant
Associate Professor,
Professor DirectorMedicine,
of Emergency of Emergency
New YorkUltrasound, Emergency
University School of
Ultrasound Fellowship
FellowshipDirector,
in MedicalDepartment ofYork
Emergency
City PoisonMedicine,
PAGE 7| Clinical Pathway For syncope evaluation itself can be costly and can subject the patient to a host Medicine; Director, Toxicology, New Control
emergency practice with caution and pragmatism. University of Texas
Center, New York, NY at Houston Medical School, Houston, TX
Syncope of risks, a careful balance must be maintained between under- and over- Maia Rutman,
Gregory M. Press,MD MD, RDMS
utilization of resources. These guidelines have been developed to assist the MedicalProfessor,
Assistant Director,Director
Pediatric Emergency
of Emergency Services,
Ultrasound, Dartmouth-
Emergency Ultrasound
Hitchcock Medical Center;ofAssistant Professor
Medicine, of Pediatric
clinician
Practice in planning an appropriate
Guideline Impactassessment.
Fellowship Director, Department Emergency University of Texas at
PAGE 8| References Emergency Medicine, Dartmouth
Houston Medical School, Houston, TX Medical School, Lebanon, NH
• In the management of acute SCD pain crises, bolus normal Scott
Maia S. M. Silvers,
Rutman, MD MD
Practice
saline Guideline Impact unless the patient is hypovolem-
is not recommended
Chair, Director,
Medical Department of Emergency
Pediatric Medicine
Emergency Services, Dartmouth-Hitchcock Medical
MayoAssistant
Center; Clinic, Jacksonville, FL
Professor of Pediatric Emergency Medicine, Dartmouth
• ic. In euvolemic
Syncope patients,
is a distinct intravenous
clinical entity hydration
that must shouldfrom
be differentiated not Medical School, Lebanon, NH
Scott Weingart, MD FACEP
Editor’s Note: To read more about this publication Scott M. Silvers,
Assistant MD Department of Emergency Medicine, Elmhurst
Professor,
and the background and methodologies for practice exceed
other 1.5 times
causes maintenance
of altered with D5 ½ NS.
states of consciousness and transient events. Hospital
Chair, Center,ofMount
Department SinaiMedicine,
Emergency School Mayo
of Medicine, New York,FLNY
Clinic, Jacksonville,
guideline development, go to:
http://www.ebmedicine.net/introduction • The initial evaluation of patients with syncope should always include Scott Weingart, MD, FACEP
• In the management of acute SCD pain crises, specific rec- Prior to Professor,
Assistant beginningDirector
this activity,
of thesee “Physician
Division CME Information”
of Emergency Critical Care,on
an electrocardiogram (ECG). Laboratory and additional testing should page 9. of Emergency Medicine, Mount Sinai School of Medicine,
ommendations exist with regard to opiate choice and adju-
be performed as directed by the history and physical examination.
Department
New York, NY
vant medications.
• Patients with ECG abnormalities; older age and associated comor-
Editor’s
Prior Note: To
to beginning thisread more
activity, seeabout
“CME this publication
Information” on page 9.
• bidities; hematocrit
In patients with SCD< 30 and
(if obtained);
suspectedhistory or presence
infection, of heart
criteria exist to and the background and methodologies for practice
failure, coronary artery disease, structural
identify candidates for outpatient treatment. heart disease, and other guideline development, http://www.ebmedicine.net/
content.php?action=showPage&pid=107&cat_id=16
high-risk factors are more likely to have short-term adverse outcomes
• Separate
and algorithms
therefore exist
require more for the evaluation
extensive diagnosisand/or
and treatment
admission.of
stroke in adults and children with SCD.
 | print | SUBSCRIBE | WEBSITE
Clinical Policy: Critical Issues In The Evaluation And Management
Of Adult Patients Presenting To The Emergency Department With
Syncope1
Annals of Emergency Medicine. 2007;49:431-444.
T
his document was developed by a subcommittee and com-
mittee organized by the American College of Emergency
Physicians (ACEP). The policy targets physicians working in
hospital-based EDs. Panel members are listed but their affiliations
and qualifications are not. The source of funding is ACEP. Conflict-of-
interest disclosures were not reported.
The group identified 3 critical questions and utilized an explicit strat-
egy for their literature search and review. Evidence was evaluated for
quality according to predefined criteria and sorted into 4 classes (I, II,
III, or X-fatally flawed). Recommendations were made based on the
strength of evidence for each question.
• Level A recommendations: Generally accepted principles for
patient management that reflect a high degree of clinical certainty.
• Level B recommendations: Recommendations for patient man-
agement that may identify a particular strategy or range of man-
agement strategies that reflect moderate clinical certainty.
• Level C recommendations: Other strategies for patient manage-
ment based on preliminary, inconclusive, or conflicting evidence, or
in the absence of any published literature, based on panel consen-
sus.
The guideline applies to adult patients presenting to the ED with
syncope. Pediatric patients are excluded, as are patients in whom the
episode of syncope is thought to be secondary to another disease
process such as seizures, chest pain, headache, abdominal pain,
dyspnea, hemorrhage, hypotension, or a new neurologic deficit.
EM Practice Guidelines Update © 2010 2
Current Guidelines For Management Of Syncope In The ED
Link: http://www.acep.org/WorkArea/DownloadAsset.aspx?id=8828
Critical Question 1: What history and physical examination data
help to risk-stratify patients with syncope?
Level A Recommendations: Use history or physical examination
findings consistent with heart failure to help identify patients at higher
risk of an adverse outcome.
Level B Recommendations:
1. Consider older age, structural heart disease, or a history of coro-
nary artery disease as risk factors for adverse outcome.
2. Consider younger patients with syncope that is nonexertional,
without history or signs of cardiovascular disease, a family history
of sudden death, and without comorbidities to be at low risk of
adverse events.
Critical Question 2: What diagnostic testing data help to risk-
stratify patients with syncope?
Level A Recommendations: Obtain a standard 12-lead ECG in
patients with syncope.
Level C Recommendations: Laboratory testing and advanced
investigative testing such as echocardiography or cranial computed
tomography (CT) scanning need not be routinely performed unless
guided by specific findings in the history or physical examination.
Critical Question 3: Who should be admitted after an episode of
syncope of unclear cause?
Level B Recommendations:
1. Admit patients with syncope and evidence of heart failure or
structural heart disease.
2. Admit patients with syncope and other factors that lead to stratifica-
tion as high-risk for adverse outcome. (See Figure, Factors That
Lead To Stratification As High-Risk For Adverse Outcome, page 3.)
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Figure. Factors That Lead To Stratification As High-Risk For

Adverse Outcome

• Older age and associated comorbidities*

• Abnormal ECG†
• Hct < 30 (if obtained)
• History or presence of heart failure, coronary artery disease,
or structural heart disease

*Different studies use different ages as threshold for decisionmak-

ing. Age is likely a continuous variable that reflects the cardiovascular
health of the individual rather than an arbitrary value.
†ECG abnormalities, including acute ischemia, dysrhythmias, or sig-
nificant conduction abnormalities. ■

Copyright © 2007, by the American College of Emergency Physicians.

Used with permission.

EM Practice Guidelines Update © 2010 3 ebmedicine.net • December 2010

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Guidelines For The Diagnosis And Management Of Syncope
(Version 2009)3
European Heart Journal. 2009;30:2631-2671.
T
his document was developed by a task force assembled by the
European Society of Cardiology in collaboration with the Euro-
pean Heart Rhythm Association (EHRA), Heart Failure Associa-
tion (HFA), and Heart Rhythm Society (HRS). A funding source is not
identified. Conflict of interest disclosures for all authors and reviewers
were reported separately.
Evidence was evaluated for quality based on criteria specified in the
preparation document and sorted into 3 levels of evidence (A, B, C).
Recommendations were graded based on the strength of evidence
for each question. Class I: evidence or agreement as beneficial/use-
ful/effective; Class IIa: conflicting evidence in favor of usefulness/
efficacy; Class IIb: usefulness/efficacy less well established; Class
III: evidence/agreement not useful/effective or may be harmful. The
guidelines are designed for “all physicians who are interested in the
field [of cardiology].” Only recommendations that pertain to emergen-
cy medicine are summarized here.
What are the diagnostic criteria with initial evaluation of patients
presenting with syncope?
Class I, Level C: Vasovagal syncope is diagnosed if syncope is as-
sociated with typical prodrome and precipitated by orthostatic stress
or emotional distress.
Class I, Level C: Situational syncope is diagnosed if syncope occurs
during or immediately after coughing, sneezing, exercising, eating,
gastrointestinal stimulation, micturition, or other precipitating events.
Class I, Level C: Orthostatic syncope is diagnosed when syncope
occurs after the patient stands up. There must be documentation of
orthostatic hypotension.
EM Practice Guidelines Update © 2010 4
Current Guidelines For Management Of Syncope In The ED
Link: http://eurheartj.oxfordjournals.org/content/30/21/2631.full.pdf+html
Class I, Level C: Arrythmia-related syncope is diagnosed by ECG
when the following are present:
• Repetitive sinoatrial block; persistent sinus bradycardia < 40
beats/minute; or sinus pauses ≥ 3 seconds
• Mobitz II second-degree or third-degree atrioventricular block
• Alternating left and right bundle branch block
• Ventricular tachycardia or rapid paroxysmal supraventricular
tachycardia
• Non-sustained episodes of polymorphic ventricular tachycardia
and long or short QT interval
• Malfunction of pacemaker or implantable cardioverter defibrillator
with cardiac pauses
When is carotid sinus massage an appropriate diagnostic
maneuver?
Class I, Level B: Carotid sinus massage is indicated for patients
greater than 40 years of age who have syncope of unknown etiology
after initial evaluation.
Class III, Level C: Carotid sinus massage should be avoided in
patients with previous transient ischemic attack or stroke within 3
months or carotid bruits unless carotid Doppler studies exclude sig-
nificant stenosis.
What testing is indicated for suspected orthostatic hypotension?
Class I, Level B: When orthostatic hypotension is suspected, manual
intermittent determination of blood pressure (both supine and during
active standing for 3 minutes) with sphygmomanometer is indicated
as initial evaluation.
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When is ECG monitoring or electrophysiology evaluation
indicated in the evaluation of syncope?
Class I, Level B: ECG monitoring or electrophysiology evaluation is
indicated for patients who have clinical or ECG features that suggest
arrythmic syncope, such as:
• Bifascicular block
• QRS duration ≥ 120 milliseconds
• Mobitz I second-degree atrioventricular block
• Asymptomatic sinus bradycardia (< 50 beats/minute), sinoatrial
block, or sinus pause ≥ 3 seconds not attributable to medication
• Non-sustained ventricular tachycardia
• Pre-excitated QRS complexes
• Long or short QT intervals
• Early repolarization
• Brugada syndrome
• ECG evidence of arrhythmogenic right ventricular cardiomyopathy
• Q-waves suggesting myocardial infarction
When is echocardiography indicated in the evaluation of
syncope?
Class I, Level B: In patients who are suspected of having structural
heart disease, echocardiography is indicated for diagnosis and risk
stratification.
EM Practice Guidelines Update © 2010 5
Current Guidelines For Management Of Syncope In The ED
When is exercise testing indicated in the evaluation of syncope?
Class I, Level C: In patients who experience syncope during or
shortly after exertion, exercise testing is indicated.
When is neurological evaluation indicated in the evaluation of
syncope?
Class I, Level C: In patients in whom transient loss of consciousness
is suspected to be epilepsy, neurologic evaluation is indicated.
Class I, Level C: When syncope is due to autonomic failure, neuro-
logical evaluation is indicated to evaluate the underlying disease.
Class III, Level B: Unless a non-syncopal cause of transient loss of
consciousness is suspected, electroencephalography, ultrasound of
the neck arteries, and computed tomography or magnetic resonance
imaging of the brain are not indicated.
What treatment is indicated for reflex causes of syncope?
Class I, Level C: For all patients, explanation of the diagnosis, pro-
vision of reassurance, and an explanation of the risks of recurrence
are indicated.
Class I, Level B: In patients with prodrome, isometric physical coun-
terpressure maneuvers are indicated. ■
Moya A, Sutton R, Ammirati F, et al. Task Force for the Diagnosis
and Management of Syncope of the European Society of Cardiology
(ESC). Guidelines for the diagnosis and management of syncope
(version 2009). Eur Heart J. 2009;30:2631-2671. By permission of
European Society of Cardiology.
ebmedicine.net • December 2010
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Editorial Comment
S
yncope as a presenting complaint may be anxiety-provoking
for both patients and ED providers. While most causes are
benign, syncope is well-recognized to signal a variety of
life-threatening conditions, including cardiac dysrhythmias or isch-
emia, subarachnoid hemorrhage, pulmonary embolism, or anemia.
In addition, syncope must be differentiated from other causes of
altered consciousness.
Several guidelines have emerged to assist the clinician with evaluation
of the patient with syncope.1,3-7 Many of these guidelines focus on an
inpatient- or outpatient-based comprehensive evaluation to determine
a cause of the event. Despite this, the etiology remains unknown in ap-
proximately 40% of patients.2 The concern of the emergency clinician
is to determine the need for immediate intervention as well as the most
appropriate setting for further evaluation, if indicated.
Syncope is, by definition, brief and transient, with spontaneous
resolution. This makes syncope distinct from metabolic disturbances
such as hypoglycemia or hypoxia, which persist until intervened
upon. In order to cause a loss of consciousness, transient ischemic
attack must either involve both cerebral hemispheres (a distinctly rare
event), or involve the reticular activating system, in which case other
signs of posterior circulation insufficiency should have been present
(ataxia, dysarthria, dysphagia, diplopia, vertigo).
Seizure is the chief syncope mimic; a careful history will usually dif-
ferentiate the two, particularly if a reliable witness can assist. Helpful
clinical features to elicit include duration (syncope will generally last
less than 5 minutes), tonic-clonic activity (syncope can be associated
with myoclonic twitches, but generally less than 15 seconds),7 neuro-
logic aura, prolonged postictal period, incontinence, or tongue-biting.
There are 3 main classifications of syncope: reflex syncope (including
vasovagal syncope, situational syncope, and carotid sinus hypersen-
sitivity), orthostatic hypotension (including autonomic failure, drug-
EM Practice Guidelines Update © 2010 6
Current Guidelines For Management Of Syncope In The ED
induced orthostatic hypotension, and volume depletion), and cardio-
genic syncope (including arrhythmia and structural heart disease).3 A
variety of dangerous non-cardiac conditions can also initially manifest
as syncope, including pulmonary embolism, subarachnoid hemor-
rhage, and any occult blood loss such as gastrointestinal hemor-
rhage, ruptured ectopic pregnancy, or ruptured abdominal aortic
aneurysm. These conditions, unlike the primary syncope syndromes,
are not episodic; a history and physical examination directed at ex-
cluding them is therefore usually adequate if no suggestive features
(focal pain, signs of hypovolemia, etc.) are present.
A systematic approach can be used to guide ED management. (See
Clinical Pathway For Syncope, page 7.) As always, the emergency
clinician must first address the ABCs and any dangerous effects of
the transient loss of consciousness, eg, head trauma from a fall. The
next priority is to distinguish syncope from its mimics. When syncope
is established as the working diagnosis, all patients should receive an
ECG and a history and physical examination directed at determining
the underlying cause. Elements of the history that may help delineate
the etiology include the report of a prodrome (“sudden” syncope is
more concerning for a cardiogenic etiology), medications and envi-
ronmental exposures which may precipitate syncope, a family history
of cardiac disease (especially sudden cardiac death), and syncope
that occurs with exertion. The physical examination should give care-
ful attention to dangerous non-cardiac causes of syncope, as well as
evidence of heart failure or the presence of a murmur.
Although a definition of change in systolic blood pressure of ≥ 20 mm
Hg or diastolic ≥ 10 mm Hg is widely quoted as evidence of orthos-
tatic hypotension, this definition was determined by consensus,8 not
based on measured physiologic data, and thus may not produce ho-
mogenous symptoms in patients presenting to the ED with orthostatic
syncope. Therefore, it may be prudent to use symptomatic response
to positional changes instead of numeric values when assessing for
orthostatic syncope. (Editorial Comment continued on page 8.)
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Clinical Pathway For Syncope

Resuscitate as necessary and address dangerous effects
from transient loss of consciousness

Perform: Is there evidence to suggest that the transient loss of con- Are there features to suggest a structural or arrhythmic
• History sciousness was a seizure? cardiac etiology?
• Physical examination • Neurological aura NO • Concerning ECG
• ECG, specifically assessing for: • Tonic-clonic movements > 15-30 seconds • Occurred during exertion or supine
l Arrhythmia • Tongue biting • Family history of sudden cardiac death
l Ischemia • Incontinence • Absence of prodrome
l Pre-excitation • Prolonged post-event confusion or lethargy • Preceded by palpitations or chest pain
l Brugada syndrome • New murmur
l Hypertrophic obstructive cardiomyopathy YES NO
l Corrected QT interval > 500 ms YES NO

Does the patient require

Neurological evaluation
further testing to exclude
non-cardiac dangerous
causes of syncope?
• Subarachnoid
hemorrhage
• Pulmonary embolism
• Aortic dissection
• Pericardial effusion
• Anemia or internal
bleeding, including:
l Gastrointestinal
tract bleeding
l Ruptured ectopic
pregnancy
l Ruptured
abdominal aortic
aneurysm
YES
Further testing.
If nondiagnostic, return to
pathway.
Inpatient
evaluation
Are there features to suggest a benign etiology?
• Stereotyped prodrome
• Noxious stimulus as a precipitant
• Positional history (supine to standing)
• History of long period of standing
• New or increased antihypertensive medications
• Stereotyped situation (eg, micturition)
• Response to carotid sinus massage
YES NO
• Routine If still undifferentiated syncope, are there
outpatient risk factors for short-term adverse events?
evaluation • Older age and associated comor-
• Physical bidities
counterpres- • Abnormal ECG
sure maneu- • Hematocrit < 30
vers • History or presence of heart failure,
coronary artery disease, or struc-
tural heart disease

YES NO

Inpatient Prompt outpatient

Abbreviation: ECG, electrocardiogram. evaluation evaluation

EM
EM Practice
Practice Guidelines
Guidelines Update
Update © 2010
© 2010 2 7 ebmedicine.net
ebmedicine.net •• December
December 2010
2010
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(Editorial Comment continued from page 6.)
The ECG is an essential component in the evaluation of syncope, as
it may demonstrate rare but potentially life-threatening pathologies. In
addition to dysrhythmias and ischemia, particular attention should be
paid to screening for pre-excitation syndromes, Brugada, and a long-
QT interval, as well as evidence of hypertrophic cardiomyopathy (left
ventricular hypertrophy and deep, narrow Q-waves, particularly in the
inferior and lateral leads).9
Patients with evident reflex-mediated syncope may benefit from
learning physical isometric counterpressure maneuvers, which are
employed at the onset of symptoms and increase systemic vascular
resistance, possibly averting subsequent loss of consciousness.10
After an appropriate ED evaluation, the cause of syncope often
remains uncertain. In these cases, disposition is determined by the
presence of features that predict short-term adverse events, as pre-
sented in the ACEP clinical policy. (See Figure, page 3.) ■

References
1. Huff JS, Decker WW, Quinn JV, et al. American College of Emergency Physicians. Clinical policy: critical issues in the evaluation and man-
agement of adult patients presenting to the emergency department with syncope. Ann Emerg Med. 2007;49:431-444. (Systematic review)
2. Soteriades ES, Evans JC, Larson MG, et al. National Heart, Lung, and Blood Institute Framingham Heart Study. Incidence and prognosis of
syncope. N Engl J Med. 2002;347(12):878-885. (Prospective, sub-group analysis; 7814 patients)
3. Moya A, Sutton R, Ammirati F, et al. Task Force for the Diagnosis and Management of Syncope of the European Society of Cardiology
(ESC). Guidelines for the diagnosis and management of syncope (version 2009). Eur Heart J. 2009;30:2631-2671. (Systematic review)
4. Linzer M, Yang E, Mark Estes NA III, et al. The Clinical Efficacy Assessment Project of the American College of Physicians. Clinical guide-
line: diagnosing syncope: part I: value of history, physical examination, and electrocardiography. Ann Intern Med.1997;126:989-996. (Sys-
tematic review)
5. Linzer M, Yang E, Mark Estes NA III, et al. The Clinical Efficacy Assessment Project of the American College of Physicians. Clinical guide-
line: diagnosing syncope: part II: unexplained syncope. Ann Intern Med. 1997;127:76-86. (Systematic review)
6. Strickberger SA, Benson W, Biaggioni I, et al. American Heart Association Councils on Clinical Cardiology, Cardiovascular Nursing, Car-
diovascular Disease in the Young, and Stroke, and the Quality of Care and Outcomes Research Interdisciplinary Working Group; and the
American College of Cardiology Foundation: In Collaboration With the Heart Rhythm Society: Endorsed by the American Autonomic Society.
AHA/ACCF scientific statement on the evaluation of syncope. Circulation. 2006;113:316-327. (Review)
7. Westby M, Davis S, Bullock I, et al. NHS National Institute for Health and Clinical Excellence. National Clinical Guideline Centre for Acute
and Chronic Conditions, Royal College of Physicians. Transient loss of consciousness ("blackouts") management in adults and young
people. http://www.nice.org.uk. Accessed October 15, 2010. (Review)
8. Kaufmann H. Consensus statement on the definition of orthostatic hypotension, pure autonomic failure and multiple system atrophy. Clin
Auton Res.1996;6(2):125-126. (Consensus statement)
9. Dovgalyuk J, Holstege C, Mattu A, et al. The electrocardiogram in the patient with syncope. Am J Emerg Med. 2007;25:688-701. (Review)
10. van Dijk N, Quartieri F, Blanc JJ, et al. Effectiveness of physical counterpressure maneuvers in preventing vasovagal syncope. J Am Coll
Cardiol. 2006;48(8);1652-1657. (Prospective, randomized; 223 patients)

EM Practice Guidelines Update © 2010 8 ebmedicine.net • December 2010

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Current Guidelines For Management Of Syncope In The ED
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Objectives: Upon completion of this article, you should be able to: 1) describe an appropriate management
strategy for patients presenting to the emergency department with syncope, based on elements of the history
and physical examination; 2) recognize causes of syncope that warrant immediate intervention; 3) determine
appropriate disposition for patients presenting to the emergency department with syncope.
Discussion of Investigational Information: As part of the newsletter, faculty may be presenting investi-
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and is not intended to promote off-label use of any pharmaceutical product.
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