Any person, 16 years and over, presenting with a brief loss of consciousness or precipitating symptoms followed by spontaneous recovery.
This protocol is intended to be used by registered and enrolled nurses within their scope of practice and as outlined in The Use of Emergency Care Assessment and Treatment Protocols (PD2024_011). Sections marked triangle or diamond indicate the need for additional prerequisite education prior to use. Check the medication table for dose adjustments and links to relevant reference texts.
Syncope may be secondary to a more serious primary condition. If this is identified, switch to the most appropriate protocol.
Consider cardiac cause.
History prompts, signs and symptoms
These are not exhaustive lists. Maintain an open mind and be aware of cognitive bias.
History prompts
- Presenting complaint
- Onset of symptoms
- Triggers, including fasting
- Associated injuries
- Pain assessment – PQRST
- Pre-hospital treatment
- Past admissions
- Medical and surgical history, including diabetes mellitus, bleeding disorder, TIA, cardiac disease, GI bleeding, seizures, PE, DVT or recent trauma
- Previous episodes of syncope
- Current medications, including anticoagulant therapy, antiarrhythmic or beta blocker medications
- Implantable medical device, e.g. PPM, AICD or VP shunt
- Non-prescription drug or alcohol use
- Known pregnancy
- Known allergies
Signs and symptoms
- Light-headedness or dizziness
- Weakness
- Blurred vision
- Hypotension
- Diaphoresis
- Nausea or vomiting
- Abdominal discomfort
- Involuntary jerking
- Anxiety
Red flags
Recognise: identify indicators of actual or potential clinical severity and risk of deterioration.
Respond: carefully consider alternative ECAT protocol. Escalate as per clinical reasoning and local CERS protocol, and continue treatment.
Historical
- Over 65 years
- Structural or coronary heart disease
- Known abdominal aortic aneurysm (AAA)
- Syncope during exertion, while supine or sitting
- Palpitations prior to syncope
- Family history of sudden cardiac death
- Severe anaemia
- Known cardiac arrhythmia or cardiac history
- Sudden onset headache
Clinical
- Altered level of consciousness
- Confusion, agitation or irritability
- Sudden onset headache
- Persistent hypotension
- Cardiac arrhythmia or palpitations
- Chest pain
- Abdominal distension or rigidity
- Suspected AAA
- Head injury
- Suspected GI bleed, e.g. melaena
- Suspected pulmonary embolism
- Suspected ectopic pregnancy
Remember adult at risk: patient or carer concern, frailty, multiple comorbidities or unplanned return.
Clinical assessment and specified intervention (A to G)
If the patient has any Yellow or Red Zone observations or additional criteria (as per the relevant NSW Standard Emergency Observation Chart), refer and escalate as per local CERS protocol and continue treatment.
Position
Assessment | Intervention |
---|---|
General appearance/first impressions | Position of comfort Consider supine positioning for patients with ongoing orthostatic hypotension |
Suspected C-spine injury | Stabilise the C-spine with in-line immobilisation and/or foam collar (appendix) |
Airway
Assessment | Intervention |
---|---|
Patency of airway | Maintain airway patency Consider airway opening manoeuvres and positioning |
Breathing
Assessment | Intervention |
---|---|
Respiratory rate and effort Auscultate chest (breath sounds) Oxygen saturations (SpO2) | Assist ventilation, as clinically indicated Consider oxygen if dyspnoeic, titrate oxygen to maintain SpO2 over 93% Patients at risk of hypercapnia, maintain SpO2 at 88–92% |
Circulation
Assessment | Intervention |
---|---|
Perfusion (capillary refill, skin warmth and colour) Pulse Blood pressure Cardiac rhythm | Assess circulation Attach cardiac monitor and complete 12 lead ECG If signs of acute coronary syndrome are identified, switch to chest pain protocol Complete bilateral blood pressure (BP) and escalate as per local CERS protocol if over 20 mmHg difference Complete postural BP and HR If hypotensive and bradycardic, switch to compromising bradycardia (suspected) protocol |
IVC and/or pathology | Insert IV cannula, if trained and clinically indicated If unable to obtain IV access, consider intraosseous, if trained |
Signs of shock: tachycardia and CRT 3 seconds and over and/or abnormal skin perfusion and/or hypotension | If signs of shock present and/or SBP less than 90 mmHg, give 250 mL of sodium chloride 0.9% IV/intraosseous bolus Repeat every 10 minutes (up to 1000 mL) until SBP over 90 mmHg or signs of shock have resolved |
Disability
Assessment | Intervention |
---|---|
GCS, pupillary response and limb strength | Obtain baseline and repeat assessment as clinically indicated |
Pain | Assess pain. If indicated, give early analgesia as per analgesia section then resume A to G assessment |
Exposure
Assessment | Intervention |
---|---|
Temperature | Measure temperature |
Skin inspection, including posterior surfaces | Check and document any abnormalities |
Fluids
Assessment | Intervention |
---|---|
Hydration status: last ate, drank, bowels opened, passed urine or vomited | Commence fluid balance chart, as required |
Nausea and/or vomiting | If present, see nausea and/or vomiting section |
Glucose
Assessment | Intervention |
---|---|
BGL |
Measure BGL If BGL less than 4 mmol/L with NO decrease in level of consciousness (Yellow Zone criteria):
If BGL less than 4 mmol/L WITH a decrease in level of consciousness (Red Zone criteria) OR the patient is unable to tolerate oral intake:
If the patient is unconscious or peri-arrest:
Once stabilised, give patient long-acting carbohydrate and continue to check BGL hourly, or as clinically indicated |
Repeat and document assessment and observations to monitor responses to interventions, identify developing trends and clinical deterioration. Escalate care as required according to the local CERS protocol.
Focused assessment
Complete secondary survey.
Consider focused assessment relevant to findings.
Precautions and notes
- Establish preceding events by obtaining a history from the patient and/or bystanders where possible.
- Differentiation between life-threatening causes and benign causes is essential.
Interventions and diagnostics
Specific treatment
Serial ECGs may be required. Discuss with a medical or nurse practitioner.
Analgesia
If pain score 1–6 (mild–moderate), give:
- paracetamol 1000 mg orally once only
- and/or ibuprofen 400 mg orally once only.
If severe pain present, give analgesia and escalate as per local CERS protocol.
Nausea and/or vomiting
If nausea and/or vomiting is present, give:
- metoclopramide 10 mg orally or IV/IM once only (over 20 years only)
- or ondansetron 4 mg orally or IV/IM. If symptoms persist after 60 minutes, repeat once, maximum dose 8 mg
- or prochlorperazine 5 mg orally once only or 12.5 mg IV/IM once only
Choice of antiemetic should be determined by cause of symptoms.
Radiology
Radiology will depend on the working diagnosis. It needs to be requested by a medical or nurse practitioner. If there is concern for urgent radiology, escalate as per local CERS protocol.
Pathology
- FBC, UEC
- Urinalysis: mid-stream (preferred), clean catch or catheter urine. If positive for nitrites and/or leucocytes send for MC&S. Keep sample refrigerated if transport delayed
- If clinically indicated: troponin, LFT, Ca/Mg/PO4
- Patient with suspected long lie: CK
- Warfarinised: INR
- If bleeding is suspected: group and hold
- Temp less than 35°C, or 38.5°C and over: take two sets of blood cultures from two separate sites
- Female of childbearing age: urine βHCG. If positive and within the first trimester, send serum βHCG for quantitative analysis
Medications
The shaded sections in this protocol are only to be used by registered nurses who have completed the required education.
Drag the table right to view more columns or turn your phone to landscape
Drug | Dose | Route | Frequency |
---|---|---|---|
1 mg | IM | Once only | |
200 mL | IV infusion over 15 minutes | Once only | |
Glucose 40% gel | 15 g | Buccal | Repeat after 15 minutes if required |
50 mL | Slow IV injection | Once only | |
Ibuprofen H, R | 400 mg | Oral | Pain score 1–10
Once only |
Over 20 years: | Oral/IV/IM | Once only | |
4 mg Maximum dose 8 mg | Oral/IV/IM | Repeat once if required after 60 minutes | |
Oxygen | 2–15 L/min, device dependent | Inhalation | Continuous |
1000 mg | Oral | Pain score 1–10 Once only | |
5 mg | Oral | Once only | |
OR | |||
12.5 mg | IV/IM | Once only | |
250 mL Maximum dose 1000 mL | IV/intraosseous | Bolus Repeat every 10 minutes (up to 1000 mL) until SBP over 90 mmHg or signs of shock have resolved |
Medications with contraindications or requiring dose adjustment are marked:
- H for patients with known hepatic impairment
- R for patients with known renal impairment.
Escalate to medical or nurse practitioner.
References
- Adler D. Assessment of upper gastrointestinal bleeding. BMJ Best Practice: BMJ Publishing Group; 2022 [cited 17 Feb 2023]. Available from: https://bestpractice.bmj.com/topics/en-gb/456
- Beasley R, Chien J, Douglas J, et al. Thoracic Society of Australia and New Zealand oxygen guidelines for acute oxygen use in adults: 'Swimming between the flags'. Respirology. 2015 Nov;20(8):1182-91. DOI: 10.1111/resp.12620
- Chew DP, Scott IA, Cullen L, et al. National Heart Foundation of Australia & Cardiac Society of Australia and New Zealand: Australian Clinical Guidelines for the Management of Acute Coronary Syndromes 2016. Heart Lung Circ. 2016 Sep;25(9):895-951. DOI: 10.1016/j.hlc.2016.06.789
- Costantino G, Sun BC, Barbic F, et al. Syncope clinical management in the emergency department: a consensus from the first international workshop on syncope risk stratification in the emergency department. Eur Heart J. 2016 May 14;37(19):1493-8. DOI: 10.1093/eurheartj/ehv378
- Gaieski DF, Mikkelsen M. Evaluation of and initial approach to the adult patient with undifferentiated hypotension and shock. UpToDate: Wolters Kluwer; 2022 [cited 20 Feb 2023]. Available from: https://www.uptodate.com.acs.hcn.com.au/contents/evaluation-of-and-initial-approach-to-the-adult-patient-with-undifferentiated-hypotension-and-shock?search=unconscious%20patient&source=search_result&selectedTitle=4~150&usage_type=default&display_rank=4
- Grossman A, Fischer C. Assessment of syncope. BMJ Best Practice: BMJ Publishing Group; 2022 [cited 17 Feb 2023]. Available from: https://bestpractice.bmj.com/topics/en-gb/248
- MIMS Australia. Clinical Resources. Australia: MIMS Australia Pty Ltd; 2022 [cited 17 Feb 2023]. Available from: https://www.mimsonline.com.au.acs.hcn.com.au/Search/Search.aspx
- NSW Emergency Care Institute. Syncope diagnosis and management pathway. Sydney: Agency for Clinical Innovation; 2015 [cited 17 Feb 2023]. Available from: https://aci.health.nsw.gov.au/__data/assets/pdf_file/0004/273388/syncope-diagnosis-and-management-pathway-updated-january-2015.pdf
- NSW Health. Australian Medicines Handbook. Australia: Australian Government, NSW; 2022 [cited 17 Feb 2023]. Available from: https://amhonline.amh.net.au.acs.hcn.com.au/
- Shen W-K, Sheldon RS, Benditt DG, et al. 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope. Journal of the American College of Cardiology. 2017;70(5):e39-e110. DOI: doi:10.1016/j.jacc.2017.03.003
- Therapeutic Guidelines. Antiemetic drugs in adults. Australia: Therapeutic Guidelines Limited; 2022 [cited 15 Feb 2023]. Available from: https://tgldcdp.tg.org.au.acs.hcn.com.au/topicTeaser?guidelinePage=Gastrointestinal&etgAccess=true#
- Wolf SJ, Hahn SA, Nentwich LM, et al. Clinical Policy: Critical issues in the evaluation and management of adult patients presenting to the emergency department with suspected acute venous thromboembolic disease. Ann Emerg Med. 2018;71(5):e59-e109. Available from: https://pubmed.ncbi.nlm.nih.gov/29681319/
Evidence informed |
Information was drawn from evidence-based guidelines and a review of latest available research. For more information, see the development process. |
Collaboration |
This protocol was developed by the ECAT Working Group, led by the Agency for Clinical Innovation. The group involved expert medical, nursing and allied health representatives from local health districts across NSW. Consensus was reached on all recommendations included within this protocol. |
Currency | Due for review: Jan 2026. Based on a regular review cycle. |
Feedback | Email ACI-ECIs@health.nsw.gov.au |
Accessed from the Emergency Care Institute website at https://aci.health.nsw.gov.au/ecat/adult/presyncope-or-syncope