Synopsis
Distinguish uncomplicated faint from cardiac syncope, seizure and postural hypotension, then order monitoring according to event frequency and act on NICE red flags.
- Syncope is transient loss of consciousness from cerebral hypoperfusion, with rapid onset, short duration and spontaneous complete recovery; confirm that true TLoC occurred before naming the cause.
- Get the witness story: posture, trigger/prodrome, colour, eyes, movements and their duration, tongue-bite site, injury, event duration, recovery confusion and focal weakness.
- Every suspected TLoC needs vital signs, cardiovascular/neurological examination, medication review and a 12-lead ECG unless an immediately life-threatening cause dictates treatment first.
Key red flags
Abnormal ECG, heart failure, TLoC during exertion, family sudden cardiac death under 40 or inherited cardiac condition, new unexplained breathlessness, or murmur; also consider urgent referral when older than 65 with no prodrome.
Investigation priorities
Reconstruct before, during and after the event and confirm genuine TLoC.
Management branches
Incomplete recovery, serious injury, persistent ABC/neurological abnormality or an active arrhythmia.
- Manage ABCDE and the immediate cause; check glucose when relevant and treat cardiac arrest/arrhythmia using the RCUK pathway.
- Do not label as a simple faint until recovery, examination and ECG support it.
Key medicines
Midodrine (licensed specialist option)2.5 mg PO three times daily initially; increase at weekly intervals according to supine/standing BP up to 10 mg three times daily. Give during daytime; last dose at least 4 hours before bed.