Syncope Guidelines 2018 - initial evaluation

TRIG
GERS

Supine position

Sitting

Standing for some period

During normal sleep

Micturation

Defecation

Swallowing

Coughing

Lauging out loud

During and after eating

Head movement

Shaving

During exercise

After exercise

Arm exercise

Startling

Palpitations

During fever

Flashing lights

Sleep deprivation

Straightening from squatting

Fear, pain, instrumentation

Heat, warmth, hot bath

during
ATTACK

Change in vision

Nausea, sweating

Neck and shoulder pain

Shout

Oral automatisms

Cyanosis

Eyes movement

Tongue bitten

Incontinence

Ataxia

Pelvic thrusting

Duration of TLOC

Onset of abn. movement

Sync vs. async movement

Numbers of movement

AFTER
MATH

Pallor

Nausea, sweating

Clear headed

Briefly disoriented

Confused for many minutes

Aching muscles not from bruises

Sleep

Practical Instructions for the 2018 ESC Guidelines for the diagnosis and management of syncope

The complete initial evalution of syncope includes...

H

history

Orthostatic BP
Physical exam
ECG

Suggestive Clinical Features

                Reflex Syncope
long Hx of recurrent syncope
after unpleasant sight, sound, smell, or pain
prolong standing
during meal
being in crowded or hot places
Prodrome: pallor, sweating, nausea, or vomiting
with head rotation or pressure on neck

               OH (orthostatic hypotension)
while or after standing
prolonged standing
standing after exertion
after meal
changes in antihypertensive or diuretic
autonomic neuropathy or parkinsonism

                Cardiac Syncope 
during exertion or when supine
sudden onset palpitation immediately followed by syncope
family history of unexplained sudden death at young age
presence of structural heart disease or coronary artery disease
ECG findings suggesting arrhythmic syncope

                (SA/AV block, preexcitation, bifascicular block,
                    LVH, Brugada pattern, TWI in V1-v4, long or short QTc, VT)
                

Red Flag

Event Detail	Syncope during exertion or while supine New chest discomfort, SOB, abd pain, or headache Sudden onset of palpitation followed by syncope
Past History	Severe structural heart disease (Low LVEF, CHF, or Old MI)
Physical Exam	Unexplained hypotension Persistent bradycardia; HR<40, in awake state and in the absence of physical training Undiagnosed systolic murmur GI bleeding
ECG	Acute ischemia High grade AV block Sinus pauses or Sinoatrial exit block BBB Old MI Prolong QT Brugada pattern VT or NSVT Dysfunctional of cardiac rhythm device

ECHOCARDIOGRAM
known heart disease, or suggestive of structural heart disease, or cardiac syncope.

ECG Monitoring
suspicion of arrhythmic syncope.