The organization of this clinical mind map is based upon urgent/emergent situations (LOC or loss of conscious at the time of evaluation) versus non-urgent/emergent situations. Non urgent/emergent situations are further divided based upon pathophysiologic mechanisms, such as orthostatic, neural, concussion, psychogenic, neurologic, Cardiogenic, and ETOH/drugs related. Among these, orthostatic, neural, concussion and psychogenic causes usually lead to transient loss of consciousness. Neurologic, Cardiogenic, and drugs and alcohol related causes may lead to transient or prolonged loss of consciousness. In case of prolonged loss of consciousness, immediate intervention must be carried out in terms of airway, breathing, and circulation management. In such situations, the patient presentation is not syncope anymore, and a clinician cannot continue to use this clinical mind map because by definition, syncope is a transient loss of consciousness, such that patients should be able to recover fully and without intervention. Based upon the above definition of syncope, there are two ways patients may present,
The patient/family reports having had syncope, and is fully conscious at the time of evaluation
The patient is unconscious at the time of evaluation, but will soon gain consciousness and fully recover without much intervention.
In the first scenario, the Epi-logical approach can be followed by first considering all probable diagnoses, reviewing vital signs, and the patient’s appearance to ensure that there is no imminent life-threatening diagnosis, and asking high yield and medium yield questions to weigh and remove anchor bias.
In the second scenario, ABC (airway, breathing and circulation) intervention must be done until the patient is stabilized. After the patient recovers from syncope, and if it is witnessed, much information would be obvious, such as the patient’s position, triggers, and preceding events. Further evaluation can then be done to reach a diagnosis.
Questions such as onset, duration of loss of consciousness, and the patient’s position at the onset of syncope help narrow the differential diagnoses. Once evidence has been accumulated about a pathophysiologic category of differentials, further questions can be asked to look for a specific etiology. For example, if the patient says that they passed out while getting up from a lying, sitting, or squatting position, the patient’s answer raises suspicion for orthostatic causes of syncope. Further questions such as recent diarrhea, volume loss, and use of blood pressure lowering drugs, can be asked to gather evidence about specific etiologies.
A physical exam can provide further guidance, and lab/imaging evaluation is necessary only if there is evidence to suspect a serious cause, such as neurologic and cardiogenic causes.