“Done Fell Out”, or DFO, is a common saying in the South to describe syncope. Although the saying is funny the diagnosis is not. Syncope accounts for about 3–5% of ED visits and 1–6% of hospital admissions. In patients >65, syncope is the 6th most common cause of hospitalization.

How do you approach the management of patients with syncope?

Causes of syncope

The most common causes of syncope are: Unknown (34-36%), Vasovagal (18-21%), and Cardiac (9.5-18%). For patients have a history of CV disease, the incidence of cardiac-related syncope also increases (Soteriades et al).
Causes of Syncope & The Presence or Absence of CV Disease 
CV Disease
CV Disease Absent 
CV Disease Present 
Cardiac Etiology

Why Does CV Disease Matter?

Bottom Line: Cardiac etiologies of syncope (red line above) have the highest associated mortality!

Do Risk Stratification Tools Work?

There is no “gold standard” evaluation for syncope, but there are several different scores and more coming out every month. Here is a list of several:

These rules are difficult to evaluate in part because of different weights on different variables contributing to the scoring system. A major problem with most of these scoring systems is that older patients are underrepresented. This is an issue because as our patient population gets older so does the incidence of syncope and the incidence of cardiac etiologies.

Bottom Line: Educated clinician judgment based on EBM guidelines (European Society for Cardiology and ACEP) seems to be the best strategy for management. Syncope prediction rules can certainly aid this process, but they do not yet fit for use alone for risk stratification in any population.

What is the ACEP Level-B Recommendation for Admission?

  • Older age and associated comorbidities (No set definition) 
  • Abnormal EKG findings (acute ischemia, dysrhythmias, or significant conduction abnormalities) 
  • Hematocrit
  • History or presence of CHF, CAD, or structural heart disease 

Does Everyone with Syncope Need a Head CT?

ACEP’s Level C recommendation states Cranial CT scanning need NOT be routinely performed unless guided by specific findings in the history or physical exam. So what are those findings?

Bottom Line: Clinicians might consider obtaining a Head CT as part of the syncope evaluation for the following findings:

  • Trauma above the clavicle 
  • Persistent neurologic deficit or complaint 
  • Age >65 
  • Sudden onset headache 
  • Patients on warfarin (coumadin)

What about using Syncope Management Units (SMUs)?

Because a definitive diagnosis cannot be established immediately, hospital admission is frequently recommended as the “default” approach to ensure patient’s safety and guarantee an expedited evaluation. The problem with this is the hospital care is expensive, and no studies to date have shown that clinical outcomes are improved by the in-patient practice approach. The concept of the SMU is like a chest pain observation unit. Place syncope patients under observation in the ED, and use a multidisciplinary team of physicians to perform the consultation, echo, telemetry, and other diagnostic tests from the ED.

Below are the findings from the Syncope Evaluation in the Emergency Department Study (SEEDS) study:


Bottom Line: This is an interesting concept and shows decreased hospital admission. This particular study, however, was poorly powered, unblinded, and had no cost-benefit analysis. A multicenter, multidisciplinary study would need to be performed to externally, validate and standardize the risk stratification scheme and concept of a SMU before implementation.


FINAL THOUGHTS on management and disposition

It is our job as emergency physicians to NOT identify a precise cause of syncope. Instead, we should aim to risk-stratify our patients: Who needs to be hospitalized (high risk) versus who can be safely discharge home (low risk) with outpatient follow up? The keys are:

  1. Use clinician judgment aided partly by risk stratification scores. 
  2. Remember ACEP’s recommendations on syncope admissions.


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Salim Rezaie, MD

Salim Rezaie, MD

ALiEM Associate Editor Clinical Assistant Professor of EM and IM University of Texas Health Science Center at San Antonio Founder, Editor, Author of R.E.B.E.L. EM and REBEL Reviews