• Witnessed? Determine whether patient experienced tonic-clonic activity while unconscious: Consider Seizure.
  • Post-ictal state 20-30 minutes of confusion once regained consciousness: Consider Seizure.
  • Tongue biting and/or diffusely sore muscles, generalized weakness: Consider seizure.

San Francisco Syncope Rule:

  • Defines high-risk criteria for patients with syncope.

Work up:

  • Telemetry: Assess for arrhythmia. Patient may need to go home with Holter monitor.
  • Carotid Doppler US: Look for stenosis of carotid arteries.
  • CT of head: Look for intracerebral hemorrhage or mass as etiology of syncope.
    • In vs out patient MRI: Further evaluation
  • Echocardiogram with Bubble study: Assess cardiac function, look for thrombus within heart, and Bubble study assess for PFO (patent foramen ovale) or other opening between chambers of the heart).
  • Neuro checks q4hrs: Monitor patient closely for changes in neurological status.
  • IV fluids – possible etiology is dehydration.
    • Measure orthostatic vitals qShift to assess for orthostatic hypotension as etiology.
  • Fall precautions.

Also consider: UDS (urine drug screen).

Syncope: Nursing perform Neuro checks q4. Fall precautions. IV fluids.

  • Orthostatic hypotension: (dehydration vs. medication side effect)
    1. Consider checking orthostatic vitals measurements. Encourage drinking more fluid and taking more time when going from lying down to sitting up to standing.
  • Vasovagal: (causes: emotional stress, prolonged standing, syncope when standing to micturate)
    1. Avoid standing for long periods of time.
  • Hypoglycemic episode
    1. Eat regular meals and snack throughout the day.
    2. Rule out Insulinoma: fasting glucose, insulin, c-peptide, and beta-hydroxybutyrate, fasting 3hr GTT (glucose tolerance test)
  • Cardiac
    1. EKG – screen for arrhythmia
    2. Bradycardia: Assess medications (beta-blockers, may need to decrease dose or D/C)
    3. Echocardiogram, Carotid Doppler US, Telemetry
    4. Holter monitor: Consider future referral to Cardiology: possible future EP study

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