Syncope - A Standard Assessment?

EpiEMS

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Is there a standard EMS workup for syncope?

Anything you always do? Tips, tricks, pitfalls?

Certainly seems like an ECG is worthwhile, for example. Does syncope necessitate an ALS assessment (i.e. anything that an EMT cannot do on scene)?
 

VentMonkey

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Is there a standard EMS workup for syncope?
12 lead, cardiac monitor/ SPO2, O2, BGL, IV. Anything that may have lead up to it (e.g., hypoglycemia, bradycardia, MI, etc.) I treat within protocols.
Anything you always do? Tips, tricks, pitfalls?
Same as above answers, Ep. Probably a good idea to get a stroke scale, as well.
Certainly seems like an ECG is worthwhile, for example. Does syncope necessitate an ALS assessment (i.e. anything that an EMT cannot do on scene)?
In our county, syncope whether it's deemed P1/ P2 (L&S), or P3 (code 2) gets an ALS response. I find most warrant an ALS work-up; often routinely, though not urgently.

I don't mind them, they're typically some of the more interesting to try and piece together calls along with AMS, and (acute) diff breathers, IMO.
Is it something BLS can handle? Sure, there's a lot of calls that can go BLS. I would love for BLS to be able to carry monitors and interpret them as such. I don't see much harm in a BLS (correctly) activating a STEMI before ALS rendezvous with them, but again "perfect EMS world", right?
 

StCEMT

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ABC, vitals, 12ld, bgl, history and med list, neuro assessment. Start there and follow accordingly based on what comes up.
 

DesertMedic66

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Same as what everyone else has said. We don't really do IVs for syncopal episodes anymore unless they are hypotensive or brady.
 

GMCmedic

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I do everything that has been mentioned as well as, dependent on then events leading up to ill check orthostatic blood pressure. If thats unremarkable I will occasionally check for orthostatic hypocapnia

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OP
EpiEMS

EpiEMS

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Thanks guys. My sense is a 12 lead is warranted, as is a BGL, and neuro assessment.

Anybody doing orthostatic VS per protocol?


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StCEMT

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It's not a protocol thing for me, but I will do it if I think it might be useful.
 

GMCmedic

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We dont have a syncope specific protocol. Its all curriculum.

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hometownmedic5

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Same as what everyone else has said. We don't really do IVs for syncopal episodes anymore unless they are hypotensive or brady.

Unless I've reached the conclusion that the syncope was a result of a transient cause(i.e. Vasovagal on the throne, psychogenic etc), then regardless of what my assessment reveals, my index of suspicion is high for an ongoing problem whatever that might end up being. Establishing access in a non emergent manner is prudent medicine in my book.

Also, and I know this argument isn't popular here, but my primary receiving hospital appreciates it when we drop a line. At my hospital, they're going to get a line in the ER for syncope regardless of hemodynamic status or other findings(again, they play under the "better to do it before you need it"). This may not fit with the cutting edge of medicine, but it's the world in which I practice. Sometimes you have to go along to get along.
 

VentMonkey

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Same, no specific protocol I'm aware of, but if my index of suspicion calls for it then orthostatic V/S are absolutely within reason. I do them fairly frequently, particularly with the W/D patients who I will find supine somewhere in their house.

@DesertMedic66 is that a county-wide approach, or more specific to PS? Also, do most syncopes in your area get sent to the lobby once the 12-lead clears?
 

captaindepth

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Just to add to the assessments here, I do a trauma assessment on most syncopes and will always look at peoples backs, chest, belly and head. Easy to forget but when Nana falls down and goes boom, you don't want to miss an obvious injury. Otherwise I will do V/S, 12 lead, BGL, neuro, and physical exam. Take a good look at events leading up to the syncope and medical hx. We have a lot of these events that turn out have a behavioral aspect as well.
 

DesertMedic66

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Unless I've reached the conclusion that the syncope was a result of a transient cause(i.e. Vasovagal on the throne, psychogenic etc), then regardless of what my assessment reveals, my index of suspicion is high for an ongoing problem whatever that might end up being. Establishing access in a non emergent manner is prudent medicine in my book.

Also, and I know this argument isn't popular here, but my primary receiving hospital appreciates it when we drop a line. At my hospital, they're going to get a line in the ER for syncope regardless of hemodynamic status or other findings(again, they play under the "better to do it before you need it"). This may not fit with the cutting edge of medicine, but it's the world in which I practice. Sometimes you have to go along to get along.
We used to be this way until just recently. Now the only time we start lines is when we (EMS) are going to give fluids, medications, or we think the patient may crash during our patient care. With a mix of this new protocol and myself being on one of our special units I have maybe started 10 IVs this month which is a very low number.
 

CALEMT

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is that a county-wide approach, or more specific to PS? Also, do most syncopes in your area get sent to the lobby once the 12-lead clears?

For IV's its dependent on the medic. Typically with the syncope's I've had its a 50/50 who gets a bed and who goes to the lobby. Depends on the hospital and how many available beds they have... if the medic has just done BLS interventions... you get the idea. They may do it different in Hemet and Riverside or they may do it the same.
 

hometownmedic5

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I totally get it. Evidence shows that unnecessary procedures provide no benefit and are potentially injurious(risk of infection, catheter embolus and such). Someday, my system may catch up to that line of thinking.

However, as a topic for discussion, is reducing the frequency of a potentially life saving and minimally invasive skill ultimately a good thing or a bad thing for the system as a whole?

Look at ETI. This is a skill that, in the dark ages of EMS, was used much much more than currently. While we can argue until Christmas whether we were ever proficient at it, there was a time simply due to volume our success rate was much higher. Now with less indication for it, SGAs becoming the go to maneuver in some places, and many many more paramedics thinning the stats, our ETI success rates are so bad the idea of taking it away from us is a real thing.

Could the same thing happen with IV skills if we stop the routine establishment of IV access for prophylactic purposes? I will say honestly that my IV skills are good not great and that the majority of my lines are courtesy lines that I myself do nothing with. If I stopped this practice, I can see my already average skills diminishing, potentially to the detriment of a critical patient.

There are of course no absolutes here. Just food for thought.
 

GMCmedic

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We still start a lot of IVs. Protocols in this area tend to be dumbed down for the lowest common denominator.

I have many uphill battles still to fight before I tackle that one. Typically most of my syncope patients get IVs because everyone is a little dehydrated (and protocols). Sometimes just a little bit of fluid is all it takes to make someone feel better.

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StCEMT

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I'm not sure I would see a huge decline by ditching courtesy lines. Sure, we all hit slumps, I recently did. That being said, I usually come across enough people in a shift that there is a high probability I will attempt 1-4 per day depending on volume and acuity and I rarely do them as courtesy lines outside of strokes and the like.

If you do run across a critical patient and can't get a line, then there are back up options.
 

NomadicMedic

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Curious why you all do a BGL on a symple syncope. Provided it's a "they passed out, now they're fine". Do you actually expect to see a BGL of 35 or do you do it because it's expected/protocol?

Not saying it's wrong, but I've never, ever seen a simple syncope not have a normal BGL

Of course, the one outlier will change the rules for everyone. :)
 

VentMonkey

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Curious why you all do a BGL on a symple syncope. Provided it's a "they passed out, now they're fine". Do you actually expect to see a BGL of 35 or do you do it because it's expected/protocol?

Not saying it's wrong, but I've never, ever seen a simple syncope not have a normal BGL

Of course, the one outlier will change the rules for everyone. :)
Sure, it's a rule out for me. I've had them come across as "LO" right around the corner from the ED. More often than not, you're right, it's benign. Again, this is coming from a paramedic who doesn't believe everyone gets a blood sugar (unlike he was taught in medic school:rolleyes:).
 

StCEMT

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Curious why you all do a BGL on a symple syncope. Provided it's a "they passed out, now they're fine". Do you actually expect to see a BGL of 35 or do you do it because it's expected/protocol?

Not saying it's wrong, but I've never, ever seen a simple syncope not have a normal BGL

Of course, the one outlier will change the rules for everyone. :)
Because I've been wrong many times before. Hell, last week alone I had 2 instances where I went in with this preconceived idea they were gonna be no big deal just to find out one was unresponsive and the other's pressures were absolute crap. Not that I expect a sugar problem to be the cause, but it's a relatively simple check that still might be worth noting to the nurse at the very least. That and there is a much higher chance I am starting an IV on these people, so if I already have a blood sample...
 

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