Synopsis
Distinguish syncope from falls, seizure and delirium through witness chronology, identify cardiac and orthostatic danger, measure postural physiology correctly, and restore function with cause-specific, medication-aware and driving-safe management.
- Syncope is transient loss of consciousness from global cerebral hypoperfusion with rapid onset, short duration and spontaneous complete recovery.
- First-line assessment is witness history, examination, capillary glucose when relevant and a 12-lead ECG; classify red flags before ordering broad tests.
- Ask posture, activity, prodrome, colour, breathing, movements, tongue injury, duration, recovery, injury, medicines and prior or family cardiac history.
Key red flags
Exertional or supine syncope, no prodrome, palpitations, heart failure, murmur or abnormal ECG requires urgent cardiovascular assessment.
Sudden collapse without warning, during exertion or supine, with palpitations or abnormal ECG is high risk.
Investigation priorities
Classify loss of consciousness and risk.
Management branches
A fall may have involved transient loss of consciousness.
- Perform ABCDE and glucose, assess injury and obtain witness chronology and medicine timing.
- Examine and obtain 12-lead ECG and correctly measured postural pressure.
Key medicines
MidodrineStart 2.5 mg orally three times daily during waking hours and increase weekly according to standing symptoms and pressure, commonly to 10 mg three times daily; take the last dose at least four hours before bed.
FludrocortisoneAn off-label specialist regimen may start 50 micrograms orally each morning and increase to 100 micrograms daily if response and safety permit.