›Cardiac monitor and defibrillator pads if unstable
›IV access
›Two large bore IV if hypotension or bleeding
›Point of care glucose
›ECG within 10 minutes
›Neuro checks frequency
›q15 minutes if concern for deterioration
›Immediate neuro escalation triggers
›New focal deficit
›Worsening mental status
›Severe headache progression
›Seizure recurrence
›Persistent vomiting with headache
Diagnostic sequencing
›Initial testing
›ECG
›Glucose
›CBC and electrolytes if indicated
›Neuro pathway testing
›If persistent focal deficit, activate stroke pathway local protocol dependent
›If thunderclap headache, CT head urgent
›If anticoagulated with head strike, CT head urgent
›Cardiac and PE pathway testing
›If chest pain or dyspnea, troponin and chest imaging strategy
›If PE concern, use pretest probability tool and D dimer strategy local protocol dependent
Therapeutics and targeted management
›Hemodynamic support
›IV crystalloid bolus
›500 mL to 1000 mL in suspected volume depletion
›Reassess BP and symptoms after bolus
›Bradycardia management if unstable
›Atropine IV 1 mg
›Repeat every 3 to 5 minutes
›Maximum 3 mg
›Transcutaneous pacing if refractory
›Tachyarrhythmia management if unstable
›Synchronized cardioversion per ACLS
›Sedation if time permits
›Seizure management if active seizure
›Lorazepam IV 2 mg
›Repeat once after 5 minutes if ongoing
›Levetiracetam IV 60 mg per kg
›Maximum 4500 mg
›Headache and SAH pathway symptoms
›Analgesia choices avoiding hypotension
›Antiemetic options with QT caution
Reassessment loop
›Reassessment timing and targets
›Repeat vitals every 30 to 60 minutes until disposition
›Repeat neuro exam after imaging or symptom change
›Review telemetry for ectopy or pauses
›Orthostatic symptoms after fluids if applicable
17Disposition/dispo28
Level of care and observation logic
›ICU criteria
›Hemodynamic instability
›Malignant arrhythmia
›Ongoing seizure activity
›Large stroke with airway risk
›SAH concern requiring neurosurgical monitoring
›Inpatient admission criteria
›Persistent focal neurologic deficit
›Abnormal neuro imaging
›Abnormal ECG with concerning pattern
›Elevated troponin with ACS concern
›Significant anemia or active bleeding
›Syncope during exertion with structural heart disease suspicion
›Observation pathway criteria
›Unexplained syncope with intermediate risk features
›Need for serial ECG or troponin
›Need for telemetry monitoring
›Discharge criteria
›Return to neurologic baseline
›No focal deficits
›No high risk ECG findings
›No serious secondary cause identified
›Reliable supervision and follow up
›Safe ambulation
Follow up and safety net
›Follow up timing
›Primary care within 3 to 7 days
›Cardiology within 1 to 2 weeks if unexplained or ECG abnormal
›Neurology within 1 to 2 weeks if seizure suspected or recurrent events
18Discharge Instructions/di24
Copy discharge instructions
›Summary
›You were evaluated for fainting and possible neurologic causes
›Your tests today did not show an emergency cause
›Activity
›No driving until cleared if seizure is possible or unexplained syncope local protocol dependent
›Avoid ladders
›Avoid swimming alone
›Hydration and triggers
›Drink fluids regularly
›Avoid prolonged standing
›Rise slowly from sitting or lying
›Medications
›Take medications as prescribed
›Do not double dose blood pressure medicines
›Return to ED now for
›New weakness or numbness
›Trouble speaking
›Severe headache
›Chest pain
›Trouble breathing
›Recurrent fainting
›Seizure like shaking
›Confusion that does not resolve
›Black or bloody stools
19References/r12
Guidelines and decision tools
›Syncope evaluation guidelines
›European Society of Cardiology syncope guideline 2018
›AHA ACC HRS syncope guideline 2017
›Emergency medicine syncope guidance
›ACEP clinical policy syncope 2007
›Updates local protocol dependent
›Decision instruments
›Canadian Syncope Risk Score derivation and validation 2016 to 2020
›San Francisco Syncope Rule 2004
›Stroke and seizure references
›AHA ASA acute ischemic stroke guideline 2019 update and subsequent updates local protocol dependent
›ILAE seizure classification 2017
Evidence & Review
Reviewed by SymptomDx Medical Team·Last reviewed
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