Risk Management Pitfall of Urgent Care Approach to the Syncopal Patient (Postscript 3 of 4)

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Urgent Care Approach to the Syncopal Patient | December 2021

“I didn’t order a pregnancy test because her abdominal pain was mild after the vasovagal event. Plus, she told me she had started her period the day before.”

Post syncopal patients with persistent symptoms such as chest pain, shortness of breath, abdominal pain, or significant headache should not be diagnosed with benign, low-risk syncope until more dangerous etiologies are investigated and excluded. The presence of vaginal bleeding should never be used to rule out ectopic pregnancy, as up to 40% of patients with ectopic pregnancy present with vaginal bleeding,1 and almost 10% of patients with ectopic pregnancy present with painless vaginal bleeding.2 If there is any possibility that pregnancy is contributing to the patient’s presentation, order the urine pregnancy test and answer the question definitively.

“It sounded like vasovagal syncope, so I didn’t get an ECG.”

Although ECGs in patients with suspected vasovagal syncope may often be normal, it is a level 1 recommendation by both the AHA and ESC to obtain an ECG in all patients with syncope. This inexpensive, noninvasive test may reveal underlying pathology that can change management dramatically.

“A witness reported a seizure, so I didn’t work up the patient for syncope.”

Witnesses often interpret any convulsive activity as a seizure. Consider features such as tongue laceration or prolonged postictal period to diagnose syncope accurately and avoid unnecessary evaluation or restrictions on activity after discharge.

“The 88-year-old patient had orthostasis, so I didn’t think he needed an ED transfer for syncope. I told him to aggressively hydrate at home and follow up with his PCP next week.”

The presence of orthostasis does not reliably exclude more serious causes of syncope, particularly in elderly patients. Orthostatic vital signs must be interpreted in the context of the history, physical examination, and other risk factors to avoid missing serious disease.

“The patient didn’t mention chest pain, so I didn’t consider pulmonary embolism.”

Pulmonary embolism is an uncommon cause of syncope but should be considered in patients with unexplained, persistently abnormal vital signs, especially hypotension, tachypnea, or tachycardia.


  1. Alsuleiman SA, Grimes EM. Ectopic pregnancy: a review of 147 cases. J Reprod Med. 1982 Feb. 27(2):101-106.
  2. Kaplan BC, Dart RG, Moskos M, et al. Ectopic pregnancy: prospective study with improved diagnostic accuracy. Ann Emerg Med. 1996 Jul. 28(1):10-17.

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Last Updated on August 22, 2022

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