Syncope is a high-yield CCS presentation because the first minute decides whether this is a benign vasovagal case or a STEMI / arrhythmia / PE / GI bleed / ruptured AAA that will deteriorate if you treat it like “just a faint.” Use this with the complete CCS guide and the cheat sheet for the exam framework; this page is the syncope order set.
The First 60 Seconds: Every Syncope Case
Assume the worst until vitals, fingerstick, and a 12-lead EKG say otherwise.
Immediate orders (before a leisurely full exam if the patient looks sick):
• IV access
• Cardiac monitor + pulse oximetry
• Fingerstick glucose STAT
• 12-lead EKG — this is the single most important order
• Oxygen only if hypoxic or in distress
Then: focused exam (cardiac, neuro, volume, occult blood if GI source is plausible)
Stat labs (almost every ER/floor syncope):
• CBC, BMP
• Troponin
• hCG if a person who can be pregnant
• Coags if you may anticoagulate or the story is GI bleed
Advance the clock 10–20 minutes for EKG and glucose. Do not send the patient home on a “vasovagal” label before you have seen the strip.
History that actually changes orders
• Exertional, no prodrome, chest pain, palpitations, family sudden death → cardiac until proven otherwise
• Standing, nausea, warmth, long prodrome → vasovagal still needs an EKG
• On standing from sitting, volume loss, GI bleed, postpartum, diuretics → orthostatic + bleed workup
• Focal neuro, seizure features, post-ictal → not “simple syncope”; see CCS seizure and CCS stroke
• After head turn, arm use, or neuro deficits → consider vertebrobasilar / steal — still image if focal
Branch Point: What the EKG Shows
Branch 1: STEMI, new ischemia, or high-risk arrhythmia
Syncope plus STEMI is ACS. Do not wait on troponin. Aspirin, anticoagulation per ACS pathway, cardiology, and the full algorithm in CCS chest pain / ACS deep dive.
VT, complete heart block, pauses, WPW with rapid AF, Brugada, long QT with pause-dependent events: monitor, pads, appropriate meds or pacing, ICU, cardiology. Do not discharge.
Branch 2: Normal EKG, high-risk history
Admit to telemetry. Serial troponins. Echo if structural disease or murmur. Consider CT PA if PE features (see chest pain PE branch). GI occult blood / CBC if anemic or melanotic story.
Branch 3: Orthostatic or volume depletion
Orthostatic vitals. Fluids if hypovolemic. Find the leak: GI bleed pathway (CCS GI bleeding), ruptured ectopic (pelvic exam, hCG, ultrasound), sepsis (fever/sepsis), adrenal crisis if relevant.
Branch 4: Neuro
True syncope is brief LOC with prompt recovery. Prolonged confusion, tongue bite, incontinence, or focal signs → seizure/stroke/SAH workup, not a 2-minute “reassurance and discharge.”
Branch 5: Clinic / low-risk
Office syncope with a classic vasovagal story, normal exam, normal EKG, and no red flags can go home with outpatient follow-up. If anything is off, transfer to ER. Same first 60 seconds apply if they look unwell in clinic.
Don't-Miss Diagnoses
1. Arrhythmia / high-grade block — Miss the EKG and the patient codes on the floor.
2. ACS / critical AS — Exertional syncope is not anxiety.
3. PE / aortic catastrophe — Hypotension, hypoxia, tearing pain, unequal pulses.
4. GI bleed or ruptured ectopic — Syncope can be the only complaint.
5. ICH / SAH — Thunderclap, trauma, anticoagulation, neuro findings.
6. Hypoglycemia — Fingerstick is not optional.
Complete Order Set: ER Syncope
Immediate: IV, monitor, pulse ox, glucose, 12-lead EKG, O2 if needed
Labs: CBC, BMP, troponin, hCG if indicated, coags / type and screen if bleeding
Imaging (selective): CXR; CT head if trauma, anticoagulation, or neuro findings; CT PA or trop/echo as the branch dictates
Consults / disposition: Cardiology for ACS/arrhythmia/structural; telemetry vs ICU vs discharge with follow-up only after a true low-risk workup
Counseling before discharge: no driving until cleared if cardiac/seizure still possible; med rec (anti-hypertensives, diuretics); follow-up appointment
Practice the opening sequence on StudyCCS cases and drill the first-minute orders on SpeedOrder.
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