Important steps doctors should use to find the cause for syncope (fainting)


Medical experts have developed a step-by-step approach that takes time, but improves patient safety

February 23, 2018

In my law practice as a Houston, Texas medical malpractice attorney, I have handled a number of cases involving a condition called syncope. Syncope is a medical term that means fainting or passing out, most often when a person’s blood pressure gets too low (hypotension), causing insufficient oxygen to get to the brain.

Emergency medicine physicians and providers routinely see a lot of patients with syncope. This is led to medical experts developing a standard of care, in the form of an algorithm, or step-by-step guide, to evaluate the cause of syncope in a patient.

History, Physical, Echocardiogram

In all patients seeking medical care because of the neck episode of syncope, the first step is for the physician or mid-level provider (nurse practitioner or physician assistant) to do three things. First, take a detailed history, which is an interview the patient and any present family members about past medical conditions, medications, and what the patient was doing at the time that syncope occurred. Second is a physical examination. Third is an electrocardiogram.

Orthostatic Hypotension or Neurocardiogenic Syncope

In some situations, the first step leads to a diagnosis for orthostatic hypotension or neurocardiogenic syncope. In those situations, the diagnostic process is over. Orthostatic hypotension refers to the phenomenon of a sudden onset of low blood pressure when a person stands up from a sitting or lying down position. It can make a person feel dizzy or lightheaded, or even can cause syncope. Neurocardiogenic syncope is also called a vasovagal response. It is a disorder of the central nervous system that causes a person’s heart rate and blood pressure to plummet suddenly.

If either of these conditions is diagnosed, providers treat them.

Unexplained Syncope

In many cases, the initial workup of history, physical, and echocardiogram does not allow identification of the cause of a patient’s syncope. In these situations, additional testing is necessary.

More Tests

The next step in the diagnostic algorithm is for the physician to order and echocardiogram, exercise test, and ischemia evaluation.

One Option: Diagnosis Achieved

The additional testing sometimes results in the diagnosis of a structural heart disease and ischemia, a condition referring to a lack of adequate blood perfusion and delivery of oxygen to vital organs, including the brain. For patients with a past medical history of a heart attack, or myocardial infarction, testing by electrophysiologist may also be done.

With a heart disease diagnosis from this workup, treatment can begin.

Another Option: Normal

On other occasions, after all of that these tests, everything comes back normal. In such instances, if there was only one benign episode of syncope, the evaluation is considered complete.

On the other hand, if the patient had more frequent episodes of syncope, the doctor should consider using a Holter monitor or an implantable loop recorder to try to match syncope symptoms with a heart rhythm. Similarly, if the episodes a syncope are more infrequent, the physician should consider using an implantable loop recorder for the same reasons.

Differential diagnosis is hard work taking focus

The process that physicians use to come up with a final diagnosis is called the differential diagnosis method. When evaluating a patient with certain symptoms, whether syncope or anything else, physicians must consider all of the potential diagnoses that could explain the patient’s problem.

Rather than rushing to judgment with limited information and inadequate testing, the standard of care requires physicians to use a comprehensive process to rule out or eliminate potential diagnoses from the list, starting with the most dangerous condition.

Today, I took the deposition of the defendant neurologist in a medical malpractice case that I am handling in Houston. Unfortunately, the neurologist chose to skip many steps in the differential diagnosis process. Although he admitted that he had not ruled out certain life-threatening potential diagnoses, like a vascular disorder, he settled on a less threatening condition for his diagnosis, a migraine headache. The patient was discharged from the hospital and shortly thereafter had a massive vascular event that left him with permanent life-changing impairments.

The syncope algorithm shows the type of steps and attention that healthcare providers should use when diagnosing a serious condition that could have many different potential causes.

We are here to help

If you or a loved one has been seriously injured as a result of the doctor’s inattention to detail or rushing through the diagnostic process, call the experienced medical malpractice attorneys at Painter Law Firm, in Houston, Texas, at 281-580-8800, for a free consultation about your potential case.


Robert Painter is an attorney at Painter Law Firm PLLC, in Houston, Texas. He represents patients and family members in medical negligence and wrongful death lawsuits against hospitals, doctors, surgeons, anesthesiologists, pharmacists, and other healthcare providers. He was honored by Martindale Hubbell with the prestigious AV rating, and was recognized as one of Houston’s top lawyers, in 2017, by H Texas magazine.

Robert Painter

Robert Painter is a medical malpractice lawyer at Painter Law Firm PLLC.


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