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Case 3: On the way to hockey practice

On Saturday morning, a 19 year old student is brought to your emergency department. He was cycling to hockey practice when he suddenly collapsed. His team mate panicked and phoned an ambulance.

When the ambulance arrived, they were both sitting at the side of the road. The patient did not appear to have sustained any injuries, and he looked well and was asymptomatic. He thought it was due to having ‘a big night out’ last night, and did not want to go to the hospital. The ambulance officers insisted, and the patient is now in your department.

The patient’s vital signs are:

GCS 15  
BP 117/76 mmHg
HR 72 /min, somewhat irregular
RR 17 /min
SpO2 99% on room air
Temp 36.9 °C
BGL 7.3 mmol/l

What are likely causes of syncope in this young man?

When the syncope is exercise-related, does this change your differential diagnosis?


On examination, you hear a systolic murmur over the heart.

What might be its significance in this context?


What are things you specifically look for in the ECG of syncope patients?


This is the ECG of your patient:ecg case3

Source: Dr Amal Mattu (with permission).

Please describe and interpret.


What further investigations will you be ordering? What specifically are you looking for?

Are consultations with other specialists warranted, and if so, do you need them today or as an outpatient?

If you are going to discharge this patient, what are your discharge instructions?

Suggested resources

Syncope − International guidelines & overview articles

  • Blanc JJ, L’Her C, Touiza A, et al. Prospective evaluation and outcome of patients admitted for syncope over a 1 year period. Eur Heart J. 2002; 23(10): 815-20.  link
  • Huff JS, Decker WW, Quinn JV et al. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department with Syncope. Ann Emerg Med. 2007; 49: 431-444.  link
  • The Task Force for the Diagnosis and Management of Syncope of the European Society of Cardiolocy (ESC). Guidelines for the diagnosis and management of syncope. Eur Heart J 2009; 30: 2631-71.  link
  • Mattu A. Syncope: A Common Sense Approach to a High Risk Problem. Free Emergency Medicine Talks. 2010.  link
  • 2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy. Circulation. 2011;124:e783-e831.  link
  • Ruwald MH, Hansen ML, Lamberts M, et al. Comparison of incidence, predictors, and the impact of co-morbidity and polypharmacy on the risk of recurrent syncope in patients <85 versus ≥85 years of age. Am J Cardiol. 2013; 112(10): 1610-5.  link
  • National Institute for Health and Care Excellence (NICE). Transient loss of consciousness (‘blackouts’) in over 16s. Updated 2014.  link
  • Peeters SYG, Hoek AE, Mollink SM, Huff JS. Syncope: Risk Stratification And Clinical Decision Making. Emerg Med Pract. 2014; 16(4).  link
  • Nickson C. Syncope. LITFL. 2014.  link
  • Patel PR, Quinn JV. Syncope: a review of emergency department management and disposition. Clin Exp Emerg Med. 2015; 2(2): 67-74.  link
  • Cook OG, Mukarram MA, Rahman OM, et al. Reasons for Hospitalization Among Emergency Department Patients With Syncope. Acad Emerg Med. 2016; 23(11): 1210-1217. link
  • Prandoni P, Lensing AW, Prins MH, et al; PESIT Investigators. Prevalence of Pulmonary Embolism among Patients Hospitalized for Syncope. N Engl J Med. 2016; 375(16): 1524-1531.  link  link

Syncope − ECG and other diagnostic tests

  • Dovgalyuk J, Holstege C, Mattu A, Brady WJ. The electrocardiogram in the patient with syncope. Am J Emerg Med. 2007; 25: 688-701.  link
  • Mendu ML, McAvay G, Lampert R, et al. Yield of Diagnostic Tests in Evaluating Syncopal Episodes in Older Patients. Arch Intern Med. 2009; 169(14): 1299-1305.  link
  • Ariathianto Y. Asymptomatic bacteriuria. Prevalence in the elderly population. Aus Fam Phys. 2011; 40(10): 805-809.  link
  • Toscano J. Review of Important ECG Findings in Patients with Syncope. Am J Clin Med. 2012; 9(2): 92-96.  link
  • Swaminathan A. Orthostatic Hypotension Debunked. 4th All NYC EM Conference. 2013.  link
  • Articles by Dr Ed Burns about ECGs in syncope (LITFL):
      • Arrhythmogenic Right Ventricular Cardiomyopathy / Epsilon wave  link  link
      • Brugada syndrome  link
      • Hypertrophic Cardiomyopathy (HCM)  link
      • Killer ECG Patterns – Deadly Diagnoses Not To Miss!!  link
      • Pre-excitation Syndromes  link
      • Sudden Syncope on the Soccer Field  link

Syncope − Decision instruments

  • Quinn JV, Stiell IG, McDermott DA, et al. Derivation of the San Francisco Syncope Rule to Predict Patients With Short-Term Serious Outcomes. Ann Emerg Med. 2004; 43: 224-232.  link
  • Quinn J, McDermott D, Stiell I, Kohn M, Wells G. Prospective Validation of the San Francisco Syncope Rule to Predict Patients With Serious Outcomes. Ann Emerg Med. 2006; 47: 448-454.  link  link
  • Sun BC, Mangione CM, Merchant G, et al. External Validation of the San Francisco Syncope Rule. Ann Emerg Med. 2007; 49: 420-427.  link
  • Cosgriff TM, Kelly A-M, Kerr D. External validation of the San Francisco Syncope Rule in the Australian context. Can J Emerg Med. 2007; 9(3): 157-61.  link
  • Thiruganasambandamoorthy V, Hess EP, Alreesi A, et al. External Validation of the San Francisco Syncope Rule in the Canadian Setting. Ann Emerg Med. 2010; 55: 464-472.  link
  • Puppala VK, Dickinson O, Benditt DG. Syncope: classification and risk stratification. J Cardiol. 2014; 63(3): 171-7.  link

Syncope − Exercise-related

  • O’Connor FG, Oriscello RG, Levine BD. Exercise-Related Syncope in the Young Athlete: Reassurance, Restriction or Referral? Am Fam Physician. 1999; 60(7): 2001-2008.  link
  • Colivicchi F, Ammirati F, Santini M. Epidemiology and prognostic implications of syncope in young competing athletes. Eur Heart J. 2004; 25: 1749-53.  link
  • Madan S, Chung EH. The Syncopal Athlete. Am Coll Cardiol. 2016.  link