Syncope Admission Workup
Decide who needs admission for syncope and run the inpatient evaluation safely.
Learning Objectives
- 1.Identify high-risk syncope warranting admission/observation.
- 2.Run a focused inpatient syncope workup.
- 3.Avoid low-yield testing and disposition errors.
Overview
Most syncope is benign, but high-risk features earn admission or observation with telemetry. The inpatient workup targets arrhythmic and structural causes.
Who to admit / observe
- •High-risk features: exertional or supine syncope, no prodrome, syncope with palpitations/chest pain.
- •Abnormal EKG (conduction disease, pre-excitation, long/short QT, Brugada, ischemia).
- •Structural heart disease or reduced EF; family history of sudden death.
- •Significant injury; concerning vitals; older age with comorbidity.
Escalate
High-risk syncope (cardiac concern) warrants telemetry/admission and physician involvement, not discharge.
Inpatient workup
- •Telemetry monitoring for arrhythmia.
- •Echo if structural disease suspected; ischemia evaluation when indicated.
- •Targeted labs (anemia, electrolytes); orthostatics.
- •Reserve broad neuro imaging for focal/atypical features.
Disposition
- •Low-risk reflex syncope with a normal EKG can often be discharged; high-risk patients stay until the dangerous causes are addressed.
Common beginner mistakes
- •Discharging exertional/warning-less syncope.
- •Over-ordering CT head/EEG for typical syncope without focal findings.
- •Skipping telemetry in a high-risk patient.
Mini cases
Older patient with exertional syncope, an abnormal EKG showing bifascicular block, and reduced EF.
Disposition?
Show answer
Multiple high-risk features — admit with telemetry and involve cardiology; this is potential dangerous conduction disease, not a discharge.
Young patient, classic vasovagal faint with prodrome, normal EKG and exam.
Disposition?
Show answer
Low-risk reflex syncope — generally safe for discharge with counseling, without an extensive inpatient workup.