In a patient who faints, we need to consider both the cause and the consequences, which means running through all body systems–paying special attention to the CARDIOVASCULAR system.

A

• C-spine injury

B: CHEST

• Collapse lung (pneumothorax) from rib fracture

C: CARDIOVASCULAR

• Cardiac arrhythmia: Heart rate (brady/tachyarrhtymias) Electrical (short PR, prolonged QT, trifascicular block) A R-wave (cardiomyop) Tension (HOCM) ST changes (PE, ACS, Brugada)
• Around heart: pericardial effusion
• RV strain: PE
• Dysfunctional LV: MI, CHF
• Incompetent valve, eg aortic stenosis
• Outflow dissection
• Volume depletion
• Abdominal bleed as cause or consequence of fall
• Soft tissue bleed, e.g. AAA
• Child-bearaing ectopic
• Urticaria: anaphylaxis
• Lactate: sepsis
• Addisonian
• Rx

D: NEURO

• Neuron: differentiate syncope from seizure
• RBC bleed as cause or consequence of syncope

E: ENDO

• Electrolyte: hypoglycemia

F: PELVIS

• Ectopic

G: ABDOMINAL

• A: liver injury
• O: splenic injury

H: HEME

• H: ANEMIA

INTOX

• Ingest: etoh
• Treat: hypoglycemics, antihypertensives, anticoagulants, sedatives, QT prolonging, diuretics
• OTC: NSAIDS and GI bleed
• X poison: carbon monoxide

J: joints, skin, bones

• abraisions, lacerations, fractures, soft tissue injuries

Putting this together, an assessment of syncope includes

• A: clear C-spine
• B: r/o pneumothorax or other cause of hypoxia
• C: get ECG, r/o pathologies of rhythm/pump/volume/tone
• D: differentiate syncope from seizure, assess for intracranial injury
• E: check glucose
• F: r/o pregnant
• G: examine abdomen
• H: consider CBC
• I: consider meds/drugs/toxins, especially in elderly
• J: r/o extremity injuries

Syncope can be a symptom of shock, requiring aggressive treatment. On the other end of the spectrum, many patients with syncope can be cleared and discharged after a good history, physical, ECG +/- beta for women of child-bearing age. Patients at higher risk might need further labs/imaging to r/o more serious causes of syncope (e.g. Dimer/CT chest r/o PE, serial trop r/o MI) or complications of syncope ( Xray +/- CT r/o c-spine or hip fracture; CT r/o intracranial/intra-abdominal), or admission for further investigations (e.g. cardiac monitoring for arrhythmia, echo for valvulopathy/cardiomyopathy). The San Francisco Syncope rule aims to catch these more serious causes of syncope with high risk “CHESS” features: CHF history, Hct <30, ECG abnormalities, Systolic BP <90.