2.1. SYNCOPE AND PRESYNCOPAL STATE IN CHILDREN AND ADULTS

Related terms

Loss of consciousness, fainting, syncope.

The purpose of providing EMS

1. Stabilization of the condition and resuscitation if necessary.
2. Start monitoring vital signs and performing diagnostic procedures.
3. Transportation to the emergency department for further examination.

Patient description

Syncope is a sign of simultaneous loss of consciousness and postural (muscle) tone, this problem can be resolved spontaneously and without medical intervention. Syncope manifests itself quite suddenly and can pass just as quickly. During the initial examination, EMS workers may find that the patient is fully conscious and oriented in space. Presyncopal state is defined as the onset of symptoms preceding loss of consciousness (syncope). This state usually lasts from several seconds to minutes and can be generally described as “near-consciousness”.

Inclusion criteria

1. Sudden loss of consciousness with loss of postural (muscle) tone.
2. Symptoms preceding the onset of syncope.

Exclusion criteria

All conditions not described above, inclusive:

1. Patients with an implicit or explicit cause of loss of consciousness (e.g., trauma – refer to the Head Trauma guideline).
2. Patients with partially impaired consciousness or coma should be managed according to the guideline “Mental Health Disorders”.

Provision of emergency medical services

Assessment of the condition

1. Medical history

1.1. Review the patient’s previous medical history, including the history of:

a) cardiovascular disease (heart disease/stroke);
b) seizures
c) recent trauma;
d) use of anticoagulant medications;
e) arrhythmia;
e) chronic heart failure;
f) syncope.

1.2. History of the current disease, including:

a) conditions leading to syncope;
b) patient’s complaints before and after syncope, including prodromal symptoms;
c) Loss of consciousness during physical activity usually indicates severe heart problems, and such patients should be evaluated in the emergency department;
d) information from other persons at the scene about seizures and tremors, pulse/breathing (if detected), duration of the seizure, events that led to normalization.

1.3. Review of systems:

a) occult blood loss (gastrointestinal tract or genitourinary system);
b) fluid loss (diarrhea/vomiting) and fluid intake;
c) medications currently being taken by the patient.

2. Physical examination of the patient includes:

a) attention to vital signs and assessment of trauma;
b) detailed neurological examination (including stroke and mental status screening)
c) cardiovascular and respiratory, abdominal and extremity examinations;
d) additional assessment:

• • • • cardiac monitoring;
      • continuous monitoring of vital signs;
      • 12-lead ECG.

Treatment and interventions

All interventions should be aimed at addressing the disorders identified during the physical examination and may include management of arrhythmias, ischemia, or during follow-up. These interventions include control of heart rate, angina/infarction, bleeding, shock, and

a) airway management (if necessary);
b) oxygen therapy (if necessary);
c) assessment of bleeding and treatment of shock, if indicated;
d) establishing intravenous access;
e) administration of fluids (if necessary);
f) cardiac monitoring;
g) 12-lead ECG;
h) monitoring and treatment of arrhythmias (if present, follow appropriate guidelines).

Patient safety

1. Patients who suffer from loss of consciousness due to arrhythmia may experience recurrent arrhythmia and therefore require cardiac monitoring.
2. Elderly patients who suffer a fall from standing may be seriously injured and should be carefully assessed for trauma (see General Trauma).

Useful information for training

Key points

1. By being as close to the scene as possible, EMS workers are in the best position to identify the causes of loss of consciousness. Consideration of all potential causes, continuous monitoring of vital signs and heart rate, as well as a detailed physical examination and history are important information to be shared with the emergency department.

2. All patients suffering from loss of consciousness need to be evaluated in the hospital, even if they appear to be in good health and have minor complaints at the scene.

3. Serious causes of loss of consciousness are:

a) cardiovascular:

• • • • myocardial infarction
      • aortic stenosis;
      • hypertrophic cardiomyopathy;
      • pulmonary embolism;
      • dissecting aortic aneurysm;
      • lethal arrhythmia;

b) neurovascular:

• • • • intracranial hemorrhage;
      • transient ischemic attack or stroke.

4. Consider the 12-lead ECG for high-risk signs, including but not limited to

a) prolonged QT interval (usually greater than 500ms);
b) delta waves;
c) Brugada syndrome (incomplete right bundle branch block (RBBB) in V1/V2 with ST-segment elevation);
d) obstructive hypertrophic cardiomyopathy.

Relevant assessment findings

1. Signs of trauma.
2. Signs of cardiac disorders (e.g., evidence of congestive heart failure (CHF), arrhythmia).
3. Signs of bleeding.
4. Signs of neurological disorders.
5. Signs of alternative etiology, including seizures.
6. Initial and subsequent heart rate.
7. ECG data in 12-leaders.

Key elements of documentation

1. Heart rhythm is present.
2. Heart rhythm during the manifestation of symptoms in the patient.
3. Any changes in the heart rhythm.

Criteria for the effectiveness of care

1. ECG in 12-lead leads.
2. Cardiac monitoring