Evaluation and Management of Dizziness and Collapse

Initial Assessment

The American College of Cardiology recommends determining the exact nature of symptoms, including true syncope versus presyncope, to guide further evaluation 1
Assessing for orthostatic hypotension by measuring blood pressure and heart rate in both supine and standing positions is crucial for diagnosis 1
Evaluating for classic orthostatic hypotension, defined as a sustained reduction of systolic BP ≥20 mmHg or diastolic BP ≥10 mmHg within 3 minutes of standing, is an important diagnostic step 1
A focused cardiac examination to detect murmurs suggesting aortic stenosis or other structural heart disease should be performed 1

The American College of Cardiology identifies higher risk features for syncope, including male sex, advancing age, history of heart failure, atrial fibrillation, aortic stenosis, impaired renal function, and AV or left bundle-branch block 1

Obtaining a 12-lead ECG to evaluate for arrhythmias, conduction abnormalities, or evidence of ischemia is a recommended diagnostic test 2
Performing transthoracic echocardiography if there is suspicion of structural heart disease, especially in patients with risk factors, is a valuable diagnostic tool 2
Checking basic laboratory tests, including complete blood count to assess for anemia 3, renal function tests as impaired renal function is a predictor of recurrent syncope 1, and glucose level to rule out hypoglycemia 4, is essential for diagnosis

For cardiac syncope, placing transcutaneous pacing pads if high-grade AV block is identified 2 and providing appropriate cardiac monitoring in a setting with resuscitation capabilities 5 are critical management steps
For orthostatic hypotension, reviewing and potentially modifying medications that may contribute to hypotension 1 is an important management consideration
For vasovagal syncope, educating on trigger avoidance and physical counterpressure maneuvers 1 and considering increasing salt and fluid intake if no contraindications exist 1 are recommended management strategies

Admission is considered for evidence of cardiac cause, inability to maintain orthostasis despite interventions 1, and presence of significant comorbidities that increase risk 1
Patients are safe for discharge with appropriate follow-up if they have a clear vasovagal or orthostatic etiology 1, a normal cardiac evaluation 1, and are able to maintain orthostasis 1

Failing to distinguish syncope from seizure, as syncope typically has rapid recovery without postictal state 1
Missing medication-induced orthostatic hypotension 1