Dizziness and Syncope
Separate benign faints from dangerous ones — high-risk features, the workup, and who needs admission.
Learning Objectives
- 1.Distinguish true syncope from presyncope and non-syncopal dizziness.
- 2.Categorize syncope and identify high-risk features.
- 3.Choose the workup and recognize who needs urgent evaluation/admission.
Overview
Syncope is transient loss of consciousness from global cerebral hypoperfusion with spontaneous recovery. Most is benign reflex syncope, but cardiac syncope carries real mortality — the history separates them.
Clarify the complaint
- •True syncope (LOC with recovery) vs presyncope (near-faint) vs dizziness/vertigo (often non-cardiac).
- •Get the event description from the patient and any witnesses.
Categories
- •Reflex/vasovagal: trigger (pain, emotion, standing, heat), prodrome, quick recovery — usually benign.
- •Orthostatic: on standing; volume depletion, autonomic, medications.
- •Cardiac: arrhythmic or structural — the dangerous group.
High-risk features
- •Exertional syncope or syncope while supine.
- •No prodrome / sudden "lights out"; syncope preceded by palpitations or chest pain.
- •Structural heart disease, reduced EF, or family history of sudden death.
- •Abnormal EKG (conduction disease, pre-excitation, long/short QT, Brugada, ischemia).
- •Injury from the episode; recurrent episodes.
Escalate
Exertional/warning-less syncope, syncope with palpitations/chest pain, or a high-risk EKG points to cardiac syncope — urgent evaluation and physician escalation, often admission.
Workup
- •EKG on everyone with syncope.
- •Orthostatic vitals; targeted labs (anemia, electrolytes) as indicated.
- •Echo if structural disease suspected; ambulatory monitoring for suspected arrhythmia.
- •Reserve broad neuro testing for focal/atypical features (most syncope is not a "stroke workup").
Disposition
- •High-risk features → urgent evaluation/admission and physician involvement.
- •Clear low-risk reflex syncope, normal EKG → often outpatient.
- •Counsel driving restrictions per local guidance for unexplained/high-risk syncope.
Common beginner mistakes
- •Treating exertional syncope as benign vasovagal.
- •Skipping the EKG.
- •Reflexively ordering a CT head/carotids for typical syncope without focal findings.
- •Not asking about family history of sudden death.
Documentation pearls
- •Document the event (pre/peri/post), high-risk features present/absent, the EKG, and the risk-based disposition.
Nurse / MA workflow connection
- •MA orthostatics and nurse triage of exertional/warning-less syncope flag high-risk patients quickly.
Mini cases
68-year-old faints suddenly while gardening, no warning, brief, then normal; EKG shows a new bifascicular block.
Risk and action?
Show answer
High-risk cardiac syncope (exertional, warning-less, abnormal conduction). Urgent evaluation/admission and physician escalation — do not treat as benign vasovagal.
22-year-old faints after a blood draw with nausea and tunnel vision, recovers quickly, normal EKG.
Likely cause?
Show answer
Classic reflex (vasovagal) syncope — clear trigger, prodrome, quick recovery, normal EKG. Reassurance and outpatient counseling are usually appropriate.