Syncope is a frequent complaint presenting to the emergency department. Just on my last shift, I saw two people with syncope as their main complaint, it has been thought to account for up to 2% of all ED visits, and 6% of all hospital admissions. So this is something we should know, the objective of this post is not to go in depth into syncope but to focus on an important diagnostic tool that we use for syncope, the ECG. Obtaining an ECG in all patients was a level A recommendation in the ACEP 2007 guidelines for syncope, it is also used in every single clinical decision rule for risk stratification. So while Emergency Medicine may not agree on what else the workup of syncope should entail(1), we seem to all agree that they at least all need a good ole ECG. Today we will be investigating some of the cant miss ECG findings of syncope, let us begin!!
#1 Right ventricular strain is another pattern that should be looked for, as this can be seen in PE, which should also be a consideration in the workup of syncope. This is a Right ventricular strain pattern seen on the ECG.
Remember there is a difference between Brudaga pattern and syndrome! See Medscape for more on this.
#3 The oft-forgotten and long named Arrhythmogenic right ventricular Cardiomyopathy or ARVC for short
Epsilon waves seen in this ECG.
For more info see LITFL!
Tall “needle-like” QRS seen on ECG.
#5 Arythmea, there are many arrhythmias that can lead to syncope blocks and VT are just a couple to keep in your Ddx
3rd degree heart block seen on ECG here.
#6 Infarction/Ischemia. MI can be a prcipitant of syncope!
#7 Intervals, gotta check those intervals for any prolonged or shortened QT or PR. etc!
Problenged QT seen here on ECG.
#8 WPW and preexcitation.
Look for Delta waves!
For more on WPW–> LITFL
Things not to miss on Hx/Physical
Remember to ask about any family history of sudden cardiac death!
Listen for that murmur, we often use the excuse that we won’t be able to hear a murmur in the busy department, but this is no excuse. We should be listening for murmur in all syncope patients especially the older patient as syncope in the setting of an aortic stenosis portends badness!(2)
This is the DotPhrase that I use when I have a negative ECG for any of the above red flags.
ECG: reveals normal sinus rhythm with a normal PR, QRS and corrected QTC interval. There is no evidence of preexcitation criteria/WPW. There also no findings to suggest right heart strain, Brugada sign, HOCM, ischemia, short or long QT syndrome, VT, nor arrhythmogenic right ventricular dysplasia.
Flashcard fun for Reveiw!
For more information and deep dives into syncope please see
- EMRAP on syncope
- EMRAP ECG in Syncope
- Recent Controversial PESIT study covered by FOAMcast
- EMbasic on syncope
- RESUS.ME This is a great blog post on ECG interpretation in syncope