First time/ happened before (when did it start happening, how often, becoming more frequent, when does it happen)
What happened?
BEFORE
What were they doing before? Were they standing/sitting/lying down? Had they gone from sitting to standing? (orthostatic hypotension)
Reflex/Neurally mediated syncope: prolonged standing/crowded place/hot/Emotion/pain/cough/sneeze/swallow/defecating/micturating/just eaten/turning head or neck eg.shaving (pressure on carotid sinus)
What’s the last thing they remember?
Were you well before? Any recent fever, diarrhoea/vomiting (dehydration leading to orthostatic hypotension)
Any warning: sweaty, feeling hot/cold, visual blurring/fields closing in, nausea/vomiting, light-headed, aura (déjà vu/taste/smell/hear/see things/funny feeling in abdomen/olfactory/gustatory hallucinations), headache/fever/numbness/weakness
Any trigger: lack of sleep, alcohol intoxication or withdrawal, illicit drug use, watching TV/flashing lights, stress, missed meal, fever, head injury, loud music, menstrual period
DURING
Onset (sudden/gradual)
How long did you lose consciousness for?
Stiff then jerking/shaking (which body part, lip smacking, picking at clothes) and did these movements begin before or after the collapse, did the head or eyes deviate, tongue biting, incontinence (urine/faeces/both)
Any witness? What did they say happened? Could you respond to them?
Colour –pale
Eyes (open/closed)
Breathing pattern
AFTER
Recovery: quick/slow, complete/incomplete
Injury
Memory of events
How did you feel after? (sleepy, aching limbs, headache, confused, weakness in arms/legs, nausea/vomiting, CP, SOB, palps)
Red flags: collapse during exercise (rather than after), on lying down/sitting, heart disease, Fx sudden cardiac death, chest pain, palpitations, SOB, orthopnoea, PND, ankle swelling (cardiac arrhythmia/structural cardiac disease/PE)
PMH: cardiac (eg. valve, rhythm, MI. Cardiac RFs: HT, DM, cholesterol, smoking) neuro (eg. stroke, head injury, migraine, epilepsy, parkinsons disease with autonomic neuropathy, cancer and brain mets), diabetes (eg. autonomic neuropathy/hypoglycaemia: hunger, sweating, light-headed, response to sugary drink, missed meals, increased insulin dose, increased exercise, alcohol)
Fx: cardiac eg. sudden cardiac death, epilepsy
Dx: any cardiac medications eg. antihypertensives, diuretics. Any new medications/dose adjustments? (orthostatic hypotension) Any medications that affect QT interval?
Sx: driving, alcohol, illicit drugs, smoking, hobbies eg. climbing/cycling/swimming (dangerous if loses consciousness), who lives at home (safety), travel, pregnancy (?ectopic)
ICE
Systems review eg. abdominal pain, skin changes (addisons)
Investigations:
CBG, BP, L+S BP
FBC (anaemia), U+E (dehydration), LFT, CRP, glucose
ECG/telemetry/24hour tape/72hour/7 day tape/reveal device
CXR
Echo
CT head/MRI head, EEG, LP
Pregnancy test
Differential Diagnosis:
Syncope
- Reflex/neutrally mediated syncope (vasovagal, carotid sinus hypersensitivity, situational)
- Orthostatic syncope (medications, autonomic neuropathy eg. PD or DM, dehydration, addison’s disease)
- Cardiovascular
- Arrhythmia (brady/tachy/inherited syndrome)
- Structural (valve, cardiomyopathy, myxoma, tamponade, aortic dissection, severe heart failure)
- Ischaemia-related (ACS)
- Cardiopulmonary (pulmonary hypertension, PE)
Seizure
Metabolic disorders eg. hypoglycaemia, hypoxia, hyperventilation with hypocapnia, addisons
Vertebrobasilar TIA
Intoxication
Subarachnoid haemorrhage
Psychiatric conditions eg. panic/anxiety
Haemorrhage
Ectopic pregnancy
Written by Dr Sarah Kennedy
Resources used to write this document include those listed in the references section of this webpage and also: