How to manage a patient presenting with syncope

Application of data

Treatment of syncope will depend on its etiology. Patients with neurally mediated syncope should be educated about avoiding or mitigating potential triggers (for example, orthostatic hypotension, emotional stress, severe cough, straining during urination) and recognizing prodromal symptoms. Such patients should also be counseled regarding physical counter-pressure maneuvers (for example, limb/abdominal contraction, leg crossing, hand grip) and increasing fluid and salt intake. Midodrine, an alpha-adrenergic vasoconstricting agent, may also be considered in patients with recurrent situational neutrally mediated syncope, to be taken an hour before situations that may induce syncope. Patients with carotid sinus syncope should be considered for pacemaker placement. For patients with orthostatic hypotension, potential exacerbating drugs should be held if possible and the patients counseled on liberalizing fluid and salt intake, along with rapid cool water ingestion and physical counter-pressure maneuvers. Abdominal binders, compression stockings, and midodrine, fludrocortisone, or pyridostigmine can also be considered. Treatment of syncope due to cardiac causes depends on the specific cause and should be based on established guidelines. Finally, PE should be treated with anticoagulation and, if needed, more aggressive measures (for example, thrombolysis).

Bottom Line

Our patient likely suffered from neurally mediated vasovagal syncope due to warm conditions, supported by a previous syncopal event under similar conditions. She should be counseled regarding potential physical counter-pressure maneuvers and increased fluid and salt intake when working under warm conditions.

Dr. Roberts, Dr. Krason, and Dr. Manian are hospitalists at Massachusetts General Hospital in Boston.