Non traumatic Transitory Lost Of Consciousness (TLOC) is a common cause of medical emergency call. Among TLOC Syncope is the most common cause. So the first challenge for an emergency professional is discerning from Syncope and non syncope situations (seizures, psychogenic, other rare causes).

2018 ESC Guidelines for the diagnosis and management of syncope
Syncope according to 2018 Guidelines definition is a “TLOC due to cerebral hypoperfusion, characterised by a rapid onset, short duration, and spontaneous complete recovery”.
Among Syncope the causes can be found in vagal reflex (Reflex syncope), a drop in blood pressure due to a deficiency of compensation in a standing position (Orthostatic syncope) and a cardiac cause of syncope (Cardiac syncope)

2018 ESC Guidelines for the diagnosis and management of syncope
But what is the role and what can and must be done on the prehospital field to understand treat and risk stratify a Syncope?
Anamnesis
Is a fundamental step to understand and risk stratify a syncope episode. It has to be targeted to collect all the important informations and to don’t loose precious time.
We can divide the information we collect in two categories.
The first kind of information we area going to ask (to bystanders and patients) is about the syncope event.
- How much the lost of consciousness lasted
- How it happened (standing, sitting or laying)
- What was the patient doing (resting or during exercise)
- What the patient felt before the syncope (palpitations, chest pain, dyspnea, dizziness, other)
- What happened during or immediately after the syncope (seizures, other)
Second step is collecting informations about the patient medical conditions. We have to focus on
- What medical condition he actually suffers or suffered in the past
- Which kind of drugs he is actually doing
After a focus anamnesis the second step is about the physical exam of the patient.
Diagnostic tests
During physical exam a rapid general neurologic and cardiac examination has to be completed, but two additional steps need to be done in a syncope patients
- Orthostatic challenge in active standin position
- Carotid sinus massage (CSM) in patients aged >40 years.
Orthostatic challenge: Standing BP evaluation has to be done after 3 minutes of active standing position with the patient fully monitored, and “abnormal BP fall is defined as a progressive and sustained fall in systolic BP from baseline value >_20 mmHg or diastolic BP >_10 mmHg, or a decrease in systolic BP to <90 mmHg” (European Society of Cardiology 2018 ESC Guidelines for the diagnosis and management of syncope).
Carotid sinus massage: A ventricular pause lasting >3 s and/or a fall in systolic BP of >50mmHg is known as carotid sinus hypersensitivity. “Carotid sinus syndrome (CSS) There is strong consensus that the diagnosis of CSS requires both the reproduction of spontaneous symptoms during CSM and clinical features of spontaneous syncope compatible with a reflex mechanism.” (European Society of Cardiology 2018 ESC Guidelines for the diagnosis and management of syncope)
12 leads EKG
It’s a fundamental diagnostic tool and has to be performed in all syncope patients.
What are the risky features we have to consider when looking to ann EKG of a syncope patients:
At least 6:
- Ischemia
- Arrithmia
- Pre-excitation/WPW
- Brugada pattern
- Hypertrophic cardiomyopathy
- Arrhythmogenic Right Ventricular Cardiomyopathy
POCUS
Is there a role for Point of Care Ultrasound in differential diagnosis and risk stratification of syncope.
Probably yes cause we can look at:
- Aorta for dissection
- VD/VS ratio for PE
- Pericardium for effusion
- EF for cardiac function evaluation
High risk VS non high risk syncope
At the end of those steps the prehospital professional has two chances.
- There is a likely cause of syncope
- The syncope is of unknown cause

2018 ESC Guidelines for the diagnosis and management of syncope
If the cause is known or very likely we have to follow the specific pathway.
In the unknown syncope we have to stratify the risk.
In prehospital field is important to look for high risk features of syncope:
- History of heart failure or other cardiac conditions
- Syncvope in supine position
- Syncope during excercise
- Dyspnea before or immediately following syncope
- Palpitations before syncope episode
- EKG abnormalities
- Persisting low blood pressure (SBP<90 mmHg) in supine positi
- Orthostatic Hypotension
Each one of those is indicative of high risk prehospital features and the patient need further ED examination.
In all other cases the clinician can decide case by case if the patient can be treated out of the hospital or need admission to ED.

References :
Michele Brignole, Angel Moya et al. European Society of Cardiology 2018 ESC Guidelines for the diagnosis and management of syncope

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Year in Review. 2019 Advanced Life Support Literature of note.
15 GenChest Compressions
Blood flow forward into the artery and backward into the vein during chest compression in out-of-hospital cardiac arrest. Open Access
Association between left ventricular outflow tract opening and successful resuscitation after cardiac arrest
Airway Management
Regurgitation and pulmonary aspiration during cardio-pulmonary resuscitation (CPR) with a laryngeal tube: A pilot crossover human cadaver study. Open Access.
Pre-hospital advanced airway management for adults with out-of-hospital cardiac arrest: nationwide cohort study. Open Access
Confirmed cardiac output on emergency medical services arrival as confounding by indication: an observational study of prehospital airway management in patients with out-of-hospital cardiac arrest. Open Access
Advanced airway management in out of hospital cardiac arrest: A systematic review and meta-analysis
Pulse Check
The POCUS pulse check: A randomized controlled crossover study comparing pulse detection by palpation versus by point-of-care Ultrasoundound
A series of case studies on detection of spontaneous pulse by photoplethysmography in cardiopulmonary resuscitation. Open Access
Cath Lab
The Evolving Role of the Cardiac Catheterization Laboratory in the Management of Patients With Out-of-Hospital Cardiac Arrest. Open Access
Coronary Angiography after Cardiac Arrest without ST-Segment Elevation
EtCO2
End-tidal carbon dioxide monitoring and load band device for mechanical cardio-pulmonary resuscitation: Never trust the numbers, believe at the curves
Epinephrine
The effects of adrenaline in out of hospital cardiac arrest with shockable and non-shockable rhythms: Findings from the PACA and PARAMEDIC-2 randomised controlled trials. Open Access
#Epi: There is no place for the use of intravenous epinephrine as a standard component of cardiac arrest resuscitation care. Open Access
Epinephrine during resuscitation of traumatic cardiac arrest and increased mortality: a post hoc analysis of prospective observational study. Open Access
The Association of the Average Epinephrine Dosing Interval and Survival With Favorable Neurologic Status at Hospital Discharge in Out-of-Hospital Cardiac Arrest
Prehospital Critical Care
The effect of prehospital critical care on survival following out-of-hospital cardiac arrest: A prospective observational study. Open Access
Cost-effectiveness of advanced life support and prehospital critical care for out-of-hospital cardiac arrest in England: a decision analysis model. Open Access
Defibrillation
Decreasing time to first shock: Routine application of defibrillation pads in prehospital STEMI
Shorter defibrillation interval promotes successful defibrillation and resuscitation outcomes
An investigation of inter-shock timing and electrode placement for double-sequential defibrillation
Extracorporeal Life Support
Extracorporeal Life Support in the Emergency Department: A Narrative Review for the Emergency Physician
Extracorporeal cardiopulmonary resuscitation for massive pulmonary embolism in a “hybrid emergency room”. Open Access
Comparison of extracorporeal and conventional cardiopulmonary resuscitation: a retrospective propensity score matched study. Open Access
The rest
Stress and decision-making in resuscitation: A systematic review. Open Access
CaRdiac Arrest Survival Score (CRASS) — A tool to predict good neurological outcome after out-of-hospital cardiac arrest
Prehospital determinants of successful resuscitation after traumatic and non-traumatic out-of-hospital cardiac arrest. Open Access
Is point-of-care ultrasound a reliable predictor of outcome during atraumatic, non-shockable cardiac arrest? A systematic review and meta-analysis from the SHoC Investigators
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