Transient LOC with spontaneous recovery
Best initial (everyone): ECG + Telemetry + orthostatic vitals + glucose (90% of syncope mortality is cardiac)
Next: Echocardiogram (structural). Head CT low-yield unless focal/trauma
Recurrent, benign features → Tilt-table (vasovagal)
Order set
- ECG
- Lying/standing BP
- Glucose
- Telemetry
- Echo if structural suspicion
Criteria
AdmitCardiac syncope, abnormal ECG, or high-risk features
ICUMalignant arrhythmia
DischargeBenign (vasovagal/orthostatic) cause, normal ECG, safety-netting
Key
- Exertional syncope → AS/HCM. Sudden, no prodrome → arrhythmia.
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
- Exertional syncope
- No prodrome
- Family history sudden death
- Abnormal ECG
Differentials
- Vasovagal
- Orthostatic
- Arrhythmia
- Seizure
- AS/HOCM/PE
Common mistakes
- Over-ordering head CT
- Discharging cardiac syncope
Disposition & follow-up
Cardiac features → admit/monitor; benign → reassure + safety advice.
Discharge package
MedicationsReview culprit drugs
Follow-upCardiology if cardiac features
LifestyleHydration/salt for vasovagal; driving advice
Warning symptomsExertional syncope, palpitations, injury
💊 Treatment detail — doses & preparation
Fludrocortisonemineralocorticoid
Dose50–200 mcg OD
Preparation100 mcg tablets
MonitorBP, K⁺, oedema
Midodrineα1-agonist
Dose2.5–10 mg TDS (last dose before 6 pm)
Preparation2.5/5 mg tablets
MonitorSupine hypertension, urinary retention
Cardiac syncope work-upsafety
DoseTelemetry + echo first — treat the cause, not the symptom
Preparation—
MonitorDriving restrictions until cause addressed
📖 ESC SyncopeReviewed July 2026