This may occur so suddenly, however, as to result in a loss in postural tone. Cataplexy is defined as a sudden, uncontrolled loss of postural tone, and to witnesses this may appear as a syncopal episode. However, patients with true cataplexy will not have a loss of consciousness.
Many of the other presentations that are commonly confused with syncope may be readily identified by health care personnel once they assess the patient and situation. Problems such as hypoglycemia, stroke, cardiac failure, hypoxia, anaphylaxis, and the like should be apparent to EMS clinicians as they obtain the history and perform a focused physical examination.
Treatment
For most cases of true syncope in the prehospital environment, needed immediate treatment is minimal. Unless witnessed by EMS personnel, the event is typically resolving, if not already resolved, by the time of their arrival. Patients should receive cardiac monitoring to evaluate for dysrhythmia. The value of IV access is debatable. However, it is certainly advised if there is a suspicion for a cardiac dysrhythmia, which may recur and require IV medication. In cases when syncope was precipitated by orthostatic changes, particularly due to hypovolemia or dehydration, initiating an isotonic IV fluid bolus may be helpful. Glucose testing is indicated. Although myocardial ischemia is an infrequent cause of syncope, its significance conveys importance to obtaining a prehospital 12‐lead ECG if the capability exists.
Disposition
Experience shows that patient disposition after EMS contact can be less than straightforward. This is particularly true for patients who, at the time of evaluation by EMS clinicians, have a problem that has seemed to resolve, are not having any complaints, and lack an obvious acute pathology that requires intervention.
Unfortunately, patients experiencing syncope frequently fall into this category. Even patients with potentially life‐threatening causes of syncope, such as dysrhythmia, may have no complaints or physical examination findings during prehospital assessment.
So, what should we do with these patients? In many EMS systems, the only two choices are to transport the patient or obtain an informed refusal of care and transport. It is rare that syncope patients require specialty referral centers, especially if they are asymptomatic at time of EMS arrival. Usually, the rare causes of syncope that may require specialty referral (e.g., myocardial infarction, subarachnoid hemorrhage, and trauma after syncope) do not present asymptomatically. Therefore, for patients who agree to transport to the ED for evaluation, the closest facility is usually appropriate.
For the patient who refuses transport, the EMS crew must decide if the patient possesses adequate decision‐making capacity, including full understanding of risks, benefits, and alternatives. The explanation of the risks is perhaps the most important issue when considering the syncopal patient’s capacity to refuse transport. It is imperative that the EMS personnel have a clear understanding of the pathologies previously mentioned and can correlate those with the patient’s presentation. The level of training of the prehospital personnel will alter the ability to determine possible pathologies, the understanding of these, and the risks of not receiving evaluation in the ED.
The prehospital environment presents a complicated and dynamic practice arena. Thus, it is impossible to cover all possibilities regarding patient presentation and disposition. In the end, it is up to the EMS clinician to ensure that the patient’s final disposition is safe and in the best interest of the patient. Although the patient’s right to make decisions regarding his or her health care, assuming decision‐making capacity, of course, is paramount and must always be respected, it is equally important that all patients fully understand the potential risks associated with their conditions and the evaluation and treatment options that exist. “Autonomy trumps beneficence,” as the saying goes, but it is imperative that the patients be appropriately educated as to the potential risks of their conditions before they make their decisions to either seek additional evaluation and treatment or refuse further medical care.
Summary
Syncope is a transient loss of consciousness with a spontaneous return to a normal, baseline mental status. It is a common complaint in prehospital settings. Although the exact etiology of syncope is frequently not ascertained, careful history and physical examination can determine the cause for the majority of those patients that can be diagnosed. Certain diagnoses, especially cardiac dysrhythmias, can be potentially life‐threatening and require proper evaluation and observation. Safe disposition of the patient requires a careful evaluation in the prehospital setting, and appropriate explanation to those who frequently have no symptoms at the time of evaluation.
References
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3 3 Thijs RD, Wieling W, Kaufmann H, van Dijk JG. Defining and classifying syncope. Clin Auton Res. 2004; 14:4–8.
4 4 Ganzeboom KS, Mairuhu G, Reitsma J, et al. Lifetime cumulative incidence of syncope in the general population: a study of 549 Dutch subjects aged 35–60 years. J Cardiovasc Electrophysiol. 2006; 17: 1172–6.
5 5 Shen WK, Sheldon RS, Benditt DG, et al. 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2017; 70:e39–e110.
6 6 Benditt D. UpToDate. Syncope in adults: Epidemiology, pathogenesis, and etiologies. Available at: https://www.uptodate.com/contents/syncope‐in‐adults‐epidemiology‐pathogenesis‐and‐etiologies? Accessed September 20, 2020.
7 7 Morag R. Syncope. July 13, 2017. Available at: emedicine.medscape.com/article/811669‐overview. Accessed September 20, 2020.
8 8 Grossman SA, Babineau M, Burke L, et al. Do outcomes of near syncope parallel syncope? Am J Emerg Med. 2012; 30:203–6.
9 9 Freeman R, Wieling W, Axelrod FB, et al. Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome. Clin Auton Res. 2011; 21:69–72.
10 10 Pérez‐Rodon J, Martínez‐Alday J, Baron‐Esquivias G, et al. Prognostic value of the electrocardiogram in patients with syncope: data from the group for syncope study in the emergency room (GESINUR). Heart Rhythm. 2014; 11:2035–44.
11 11 Task Force for the Diagnosis and Management of Syncope, European Society of Cardiology, European Heart Rhythm Association, Heart Failure Association, et al. Guidelines for the diagnosis and management of syncope. Eur Heart J. 2009; 30:2631.
CHAPTER 17 Seizures
J. Stephen Huff
Introduction
Generalized convulsive seizures are frightening to observe and often result in EMS calls. Provoked seizures represent symptoms of an acute underlying medical or neurologic condition. However, seizures often occur without clear etiology or provocation. Epilepsy, sometimes referred to as a seizure disorder, is defined by recurrent unprovoked
