🩺 Syncope

Syncope is defined as a transient loss of consciousness (TLoC) due to global cerebral hypoperfusion, characterised by rapid onset, short duration, and spontaneous complete recovery. It is a frequent cause of hospital admission, especially in the elderly. The clinical priority is identifying patients at risk of sudden cardiac death versus those with benign reflex syncope. Management involves addressing underlying causes and advising on lifestyle modifications or device therapy.

Ask the patient and witnesses about the events before, during, and after the episode. Before: Were there triggers (pain, sight of blood) or a prodrome? During: Duration of unconsciousness, skin colour (pallor vs cyanosis), and presence of jerking (note: brief myoclonus can occur in simple faints). After: How quickly did they recover? Rapid recovery is typical of syncope; slow recovery suggests seizure. Review medications, especially antihypertensives and diuretics.

Check for orthostatic hypotension by measuring BP lying and after 3 minutes of standing (a drop of >20mmHg systolic is significant). Perform a full neurological exam to rule out focal deficits. Auscultate for murmurs, specifically looking for Aortic Stenosis (ejection systolic murmur) or HOCM. Assess for signs of trauma sustained during the fall, which might suggest a lack of protective reflexes and thus a sudden cardiac cause.

Vasovagal Syncope (Situational/Emotional), Orthostatic Hypotension, Cardiac Arrhythmia (Brady/Tachy), Structural Heart Disease (Aortic Stenosis), Seizure, Hypoglycaemia, Transient Ischaemic Attack (rarely causes syncope).

Syncope while supine; syncope during exercise; palpitations preceding loss of consciousness; family history of sudden death; abnormal 12-lead ECG; syncope with no prodrome.

A 12-lead ECG is mandatory for every patient to look for long QT, heart block, WPW, or signs of past MI. Bloods should include FBC, U&Es, and glucose. If structural heart disease is suspected, an Echocardiogram is required. For recurrent unexplained syncope, a Tilt Table Test or an Internal Loop Recorder (ILR) may be considered. Carotid sinus massage is sometimes performed under controlled settings if Carotid Sinus Hypersensitivity is suspected.

Vasovagal syncope is the most common cause and usually has a clear prodrome (sweating, warmth, nausea). In contrast, cardiac syncope often occurs with no warning or during exertion. Always distinguish syncope from seizure; seizures usually involve prolonged post-ictal confusion (>15 mins), tongue biting (lateral), and tonic-clonic movements. The '3 Ps' for vasovagal are: Precipitants, Prodrome, and Positional change.

Covers both the 'Syncopal attacks and dizziness' and 'Blackouts and 'faints'' sections of the MLA. Highlights the importance of the DVLA driving restrictions for patients with syncope and the need for medication reviews in the elderly.