Syncope: documentation that holds up
Most syncope is benign, but a handful of causes drop the patient dead the next time. The defensible chart shows you actively considered the catastrophic causes, interpreted the ECG, and tied the admit-or-discharge decision to short-term risk — not a gut feeling.
▸Critical pathway
Original, evidence-based synthesis — the critical diagnoses you cannot miss, the tests that catch them, and the interventions that can’t wait. Apply local protocol and judgment.
- Immediate 12-lead ECG and continuous monitoring; orthostatic vitals; fingerstick glucose; pregnancy test in patients of reproductive potential.
- If hypotensive or with ongoing symptoms: consider occult hemorrhage (AAA, GI, ectopic) and massive PE; resuscitate and obtain bedside ultrasound.
- 12-lead ECG (the single highest-yield test)
- Hemoglobin and a pregnancy test where relevant
- Targeted imaging — bedside aorta/FAST, CT for PE or SAH — driven by the history
Arrhythmia / cardiac syncope
- Trigger
- Exertional or supine syncope, palpitations, structural heart disease, abnormal ECG
- Test
- ECG, telemetry; echo for structural disease
- Intervention
- Monitored bed; treat the underlying rhythm; cardiology
Occult hemorrhage (AAA, GI, ectopic)
- Trigger
- Syncope with abdominal/back pain, melena, or positive pregnancy test
- Test
- Hemoglobin, bedside ultrasound, type and cross
- Intervention
- Resuscitation and emergent surgical/OB consultation
Pulmonary embolism
- Trigger
- Syncope with dyspnea, hypoxia, or tachycardia
- Test
- Pretest probability then CTPA
- Intervention
- Anticoagulation; thrombolysis if massive
Subarachnoid hemorrhage
- Trigger
- Syncope with severe headache
- Test
- Non-contrast head CT
- Intervention
- Blood-pressure control and neurosurgery
A reflex/vasovagal pattern with a normal ECG and exam in a low-risk patient is dischargeable; cardiac features, exertional events, or an abnormal ECG warrant monitoring and risk stratification.
01What's at stake
The ED job in syncope is risk stratification for short-term serious events, not a definitive diagnosis. Cardiac syncope carries real sudden-death risk, and several vascular catastrophes present as a faint. The two recurring failures: not documenting the ECG interpretation, and discharging a high-risk patient without recording why they were judged low-risk.
02Can't-miss causes
- Cardiac — arrhythmia (long QT, Brugada, WPW, heart block, VT) and structural disease (aortic stenosis, HOCM, low EF).
- Pulmonary embolism — syncope can be the only sign.
- Aortic dissection and ruptured AAA.
- Ruptured ectopic pregnancy and other occult hemorrhage (GI bleed).
- Subarachnoid hemorrhage; and distinguish a true seizure.
03History & exam red flags
- Exertional syncope, or syncope while supine? → cardiac
- No prodrome / abrupt, or palpitations beforehand? → arrhythmia
- Family history of sudden death <50, known cardiac disease, age >60? → high risk
- Chest pain, dyspnea, abdominal/back pain, headache with the event? → ACS/PE/dissection/AAA/SAH
- Murmur (AS/HCM) on exam; abnormal vitals; evidence of bleeding. → high risk
- Tongue biting, post-event confusion, aura → favors seizure over syncope.
Skip the typing
Work the case in the Syncope Workup — it records the ECG, orthostatics, and the Canadian Syncope Risk Score, and assembles an MDM that documents the can't-miss causes were considered and the disposition reasoning.
04Testing — the ECG is the one constant
- 12-lead ECG on essentially everyone — hunt for QTc >480 ms, QRS >130 ms, abnormal axis, significant Q waves, ischemia, pre-excitation, Brugada pattern, and brady/tachyarrhythmia.
- Targeted, not shotgun — labs/CT/echo only when the history, exam, or ECG point there (e.g., hCG for occult ectopic, troponin for suspected ACS, echo for a murmur).
- Monitoring/admission when you suspect a dysrhythmia that observation could capture and act on.
05Risk tools & evidence
- Canadian Syncope Risk Score — predisposition to vasovagal symptoms (−1), heart disease (+1), SBP <90 or >180 (+2), elevated troponin (+2), abnormal QRS axis (+1), QRS >130 ms (+1), QTc >480 ms (+2), ED diagnosis of vasovagal (−2) or cardiac (+2) syncope; higher scores predict 30-day serious events. Thiruganasambandamoorthy V, et al. CMAJ. 2016.
- San Francisco Syncope Rule (CHESS) — CHF, Hct <30%, ECG abnormality, shortness of breath, SBP <90; a screen used after the obvious admits are removed (validation accuracy lower than derivation). Quinn J, et al. Ann Emerg Med. 2004.
- Guidance — ACEP clinical policy (Huff JS, et al. Ann Emerg Med. 2007) and the 2017 ACC/AHA/HRS guideline; both anchor disposition to short-term adverse-outcome risk.
06What to document
07Where charts fail
- No documented ECG interpretation — the one near-universal test.
- Calling it vasovagal without documenting the absence of exertional/supine onset, prodrome, and family history.
- Not recording that PE, dissection, AAA, ectopic, and SAH were considered.
- Discharging a high-risk patient without a documented risk score and disposition rationale.
- Confusing syncope with seizure (or vice versa) without the discriminating features.
08Sources
- Huff JS, Decker WW, Quinn JV, et al. ACEP clinical policy: critical issues in the evaluation and management of adult patients with syncope. Ann Emerg Med. 2007;49(4):431-444.
- Shen WK, Sheldon RS, Benditt DG, et al. 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope. Circulation. 2017;136(5):e60-e122.
- Thiruganasambandamoorthy V, Kwong K, Wells GA, et al. Development of the Canadian Syncope Risk Score. CMAJ. 2016;188(12):E289-E298.
- Quinn JV, Stiell IG, McDermott DA, et al. Derivation of the San Francisco Syncope Rule. Ann Emerg Med. 2004;43(2):224-232.
- Reed MJ, Newby DE, Coull AJ, et al. The ROSE (Risk Stratification of Syncope in the Emergency Department) study. J Am Coll Cardiol. 2010;55(8):713-721.
© 2026 Kim Trinh, MD. All rights reserved. Educational only — synthesized from ACEP/AHA guidance and primary literature. Synthetic examples. Not medical advice — apply local protocol and judgment.