Download Syncope

Adult Emergency Nurse Protocol
20XX
SYNCOPE
Aim:


Early identification and treatment of life threatening causes of syncope e.g. arrhythmia, hypovolaemia & escalation of care for
patients at risk.
Early initiation of treatment / clinical care and symptom management within benchmark time.
Assessment Criteria: On assessment the patient may have one or more of the following signs / symptoms:

History of faint / brief LOC

Diaphoresis

Nausea or vomiting

Light headedness / weakness

Confusion / anxiety

Blurry or dim vision
Escalation Criteria: Immediate life-threatening presentations that require escalation and referral to a Senior Medical Officer (SMO):

Cardiac Arrhythmia

Hypotension & tachycardia

Suspected Ectopic pregnancy

Suspected Pulmonary Embolism

Haematemasis

Suspected Stroke / TIA

Blood in Stool - Malaena

Abdominal distension / rigidity

Seizures / Postictal
Primary Survey:


Airway: patency
Circulation: perfusion, BP, heart rate, temperature


Breathing: resp rate, accessory muscle use, air entry, SpO2.
Disability: GCS, pupils, limb strength
Notify CNUM and SMO if any of the following red flags is identified from Primary Survey and Between the Flags criteria.1

Airway - at risk

Breathing - Respiratory distress

Circulation – shock / altered perfusion

Partial / full obstruction

RR < 5 or >30 /min

HR < 40bpm or > 140bpm

SpO2 < 90%

BP < 90mmHg or > 200 mmHg

Disability - decreased conscious level

Exposure

Capillary return > 2 sec

GCS ≤ 14 or any fall in GCS by 2
points

Temperature < 35.5°C or > 38.5°C

Postural drop > 20mmHg

BGL < 3mmol/L or > 20mmol/L
History:








Presenting complaint
Allergies
Medications: Anticoagulant Therapy, Anti-hypertensives, Diabetic meds, Analgesics, Inhalers, Chemotherapy, Non-prescription
meds, Any recent change to meds
Past medical past surgical history relevant
Last ate / drank & last menstrual period (LMP)
Events and environment leading to presentation i.e. Red flags – palpitations, syncope with exercise, chest pain, palpitations,
back pain, haematemesis / melaena before the syncopal episode.
Pain Assessment / Score: PQRST (Palliating/ provoking factors, Quality, Region/radiation, Severity, Time onset)
Associated signs / symptoms: chest pain, palpitations, low blood pressure, dizziness, lightheadedness, any associated injuries
Systems Assessment:


Focused cardiac & neurological assessment: Inspection / Palpation / Auscultation
Identify location of pain i.e. look for any signs of injury or illness.

BP should be checked in the upper extremity bilaterally in supine and standing positions.

Pulse rate and rhythm are useful in the diagnosis of arrhythmias and Pulmonary Embolism.

Cardiac auscultation may reveal murmurs of aortic stenosis and pulmonary arterial hypertension.

Presence of sensory, motor, speech, and vision deficits suggests an underlying neurological problem.
Notify CNUM and SMO if any of the following red flags is identified from History or Systems Assessment.
 Chest pain / palpitations
 Acute Coronary Syndrome (ACS)
 Decreased LOC
 Elderly > 65years
 Anticoagulant therapy
 Acute confusion / agitation
 Severe headache
 Postural drop > 20mmHg
 Trauma head / neck
Investigations / Diagnostics:
Bedside:

BGL: If < 3mmol/L or > 20mmol/L notify SMO 

ECG: look for Arrhythmia , AMI 

Urinalysis / MSU & βHCG

Postural Blood Pressure (3mins > 20mmHg)


Laboratory / Radiology:
Pathology: Refer to local nurse initiated STOP
Quantitative ßHCG if urine positive for same
Group and Hold (if bleeding suspected)
Blood Cultures (if Temp≥38.5 or ≤35°C)
Radiology: Refer to local nurse initiated STOP
Nursing Interventions / Management Plan:
Syncope – Adult Emergency Nurse Protocol
Page 1
Adult Emergency Nurse Protocol
20XX
SYNCOPE
Resuscitation / Stabilisation:

Oxygen therapy & cardiac monitor [as indicated]

IV Cannulation (consider large bore i.e. 16-18gauge)

IV Fluids: Sodium Chloride 0.9% 1 L IV stat versus over
8 hours (discuss with SMO)
Symptomatic Treatment:

Antiemetic: as per local nurse initiated standing order

Analgesia: as per local nurse initiated standing order

IV Fluids: as per local nurse initiated standing order
Supportive Treatment:



Nil By Mouth (NBM)
Monitor vital signs as clinically indicated
(BP, HR, T, RR, SpO2)
Monitor neurological status GCS hourly

Fluid Balance Chart (FBC)

Monitor pain assessment / score
Practice Tips / Hints:

When a patient presents to the emergency department, it is important to correctly differentiate benign neurocardiogenic causes
of syncope from life-threatening causes of syncope. A detailed account of the event should be taken from the patient / family or
bystander 2

Precipitating factors, signs and symptoms, patient's position at the time of event, duration of syncope, recovery time, and family
history are all important points to be considered 2.

Red flag symptoms of potentially life-threatening causes of syncope are syncope with exercise, chest pain, palpitations, back
pain, haematemesis, and melaena before the syncopal episode. Palpitations before loss of consciousness are a significant
predictor of a cardiac cause of syncope 2.

Situational syncope with activities including coughing, swallowing, micturition, and defecation suggests that the cause is
neurocardiogenic or vasovagal 2.

Neurocardiogenic syncope is frequently recurrent and precipitated by fatigue, hot environment, severe pain, starvation, alcohol
consumption, emotional or stressful situations, and prolonged standing. The patient is usually in the standing position and
complains of symptoms of feeling weak, nausea, diaphoresis, palpitations, and blurring of vision 2.

Patients with exertional syncope and positive family history of syncope or sudden cardiac death are at increased risk of sudden
death and need to be evaluated further to rule out cardiac causes of syncope such as prolonged QT syndrome 2.
Reference: http://bestpractice.bmj.com.acs.hcn.com.au/best-practice/monograph/248/diagnosis/step-by-step.html
Further Reading / References:
1.
SESLHD Patient with Acute Condition for Escalation (PACE): Management of the Deteriorating Adult and Maternity
Inpatient SESLHD/PR283.
http://www.seslhd.health.nsw.gov.au/Policies_Procedures_Guidelines/Clinical/Other/SESLHDPR283-PACEMgtOfTheDeterioratingAdultMaternityInpatient.pdf
2.
BMJ Best Practice - Assessment of Syncope (CIAP) http://bestpractice.bmj.com.acs.hcn.com.au/bestpractice/monograph/248/diagnosis/step-by-step.html
3.
Huff, J.S; Decker W; Quinn J. et al (2007) Clinical Policy: Critical Issues in the Evaluation and Management of Adult
Patients Presenting to the Emergency Department with Syncope. Annuals of Emergency Medicine (49) 431-444.
http://www.nursingconsult.com/nursing/guidelines/article?guideline_id=189227&parentpage=search
Acknowledgements: SESLHD Adult Emergency Nurse Protocols were developed & adapted with permission from:

Murphy, M (2007) Emergency Department Toolkits. Westmead Hospital, SWAHS

Hodge, A (2011) Emergency Department, Clinical Pathways. Prince of Wales Hospital SESLHD.
Revision & Approval History
Date
Revision No.
Syncope – Adult Emergency Nurse Protocol
Author and Approval
Page 2