Syncope and Collapse: Examination

A comprehensive clinical examination is the basis for selecting further diagnostic steps:

  • Assessment of consciousness using the Glasgow Coma Scale (GCS).
  • General physical examination – including blood pressure, pulse, body weight, height; furthermore:
    • Inspection (viewing).
      • Skin and mucous membranes [signs of injury due to a possible fall event?, signs of dehydration (dehydration)?]
      • Signs of right heart failure (right heart weakness):
        • Neck vein congestion? (50-70% of cases in pulmonary embolism).
        • Liver congestion (palpable pressure-sensitive liver)?
        • Central cyanosis (bluish discoloration of skin and central mucous membranes (e.g., tongue))? (20% of cases in pulmonary embolism).
    • Auscultation (listening) of the heart and carotids [eg. E. Aortic murmur due toaortic stenosis / narrowing of the outflow tract of the left ventricle]
    • Auscultation of the lungs
    • Palpation (palpation) of the abdomen (abdomen) (tenderness?, knocking pain?, coughing pain?, defensive tension?, hernial orifices?, kidney bearing knocking pain?)
  • Basic neurological examination (e.g., to detect latent focal deficits/dysfunction of the nervous system).
  • Carotid sinus massage (provocation test): performed when vasovagal syncope is suspected in association with cervical stimulation, as well as in patients over 60 years of age with etiologically unclear syncope [ESC guideline]Performed with ECG lead and continuous blood pressure measurement; massage at La Gomera of the carotid arteries for 10 seconds; if test is negative, repeat maneuver in standing position (on tilt table if possible)Positive findings, ie. i.e., hypersensitive carotid sinus: asystole ≥ 3 seconds and/or systolic blood pressure drop greater than 50 mmHgContraindications: large, irregular plaques or stenoses greater than 70% of the carotid arteries (= absolute contraindication); other absolute contraindications include: TIAs (transient ischemic attack: sudden circulatory disturbance of the brain, leading to neurological disorders that regress within 24 hours), strokes or cerebral infarctions within the last 3 months.
  • Performance of the Wells score to determine the clinical likelihood of pulmonary embolism (see below)Note: One in six severe syncope episodes is responsible for pulmonary embolism.

Glasgow Coma Scale (GCS) – scale for estimating a disorder of consciousness.

Criterion Score
Eye opening spontaneous 4
on request 3
on pain stimulus 2
no reaction 1
Verbal communication conversational, oriented 5
conversational, disoriented (confused) 4
incoherent words 3
unintelligible sounds 2
no verbal reaction 1
Motor response Follows prompts 6
Targeted pain defense 5
untargeted pain defense 4
on pain stimulus flexion synergisms 3
on pain stimulus stretching synergisms 2
No response to pain stimulus 1

Assessment

  • Points are awarded for each category separately and then added together. The maximum score is 15, the minimum 3 points.
  • If the score is 8 or less, a very severe brain dysfunction is assumed and the there is a risk of life-threatening respiratory disorders.
  • With a GCS ≤ 8, securing the airway by endotracheal intubation (insertion of a tube (hollow probe) through the mouth or nose between the vocal folds of the larynx into the trachea) must be considered.

Wells score for determining the clinical probability of pulmonary embolism

Symptoms Points
Clinical signs or symptoms of deep vein thrombosis of the leg 3
Alternative diagnosis less likely than pulmonary embolism 3
Heart rate > 100 1,5
Immobilization or surgical procedure in the past four weeks 1,5
Previous deep vein thrombosis/pulmonary embolism 1,5
Coughing up blood (hemoptysis) 1
Tumor disease (under therapy, after therapy within the last 6 months, or palliative therapy) 1
Clinical probability of pulmonary embolism
Low-risk group (cut-off of the sum value). < 3
Medium-risk group 3,0-6,0
High-risk group (cut-off of the sum value). > 6