Syncope and trauma. Are syncope-related traumatic injuries the key to find the specific cause of the symptom?

Syncope is a prevalent disorder, accounting for 3–5% of emergency department (ED) visits and 1–3% of hospital admissions. A cardiac cause of syncope is an independent predictor of sudden death, and mortality rates are higher in patients with cardiac syncope compared with those of non-cardiac or unknown origin. In addition, significant morbidity may result from falls or accidents resulting from syncope. Bartoletti et al. have provided valuable information about the prevalence and the characteristics of secondary trauma among patients referred to the ED for a transient, self-limited loss of consciousness (TLOC). A total of 1114 patients with a true syncope and 139 individuals with a non-syncopal condition (including seizures, cerebrovascular accidents, dizziness, intoxication, hypoglycaemia, and psychogenic disorders) who presented during a period of 24 months were enrolled in this single-centre study. Among the 1253 consecutive patients with TLOC, 365 reported a trauma, which was classified as severe in 59 cases. The prevalence and the location of trauma did not differ significantly between patients with syncope and individuals with nonsyncopal conditions. Among patients with true syncope, traumatic injuries were more frequent when syncope occurred at home, in the orthostatic position, and without prodromal symptoms. As expected, older age, syncope at home, and TLOC in an upright position were associated with severe trauma. Syncope at home as a predictor of trauma seems to reflect patient characteristicts that are associated with increased risk of injury, including advanced age, cognitive impairment, and reduced physical activity. Falls account for 90% of hip fractures, and the risk of falling increases with age as a result of impaired regulation of cerebral blood flow and polypharmacy. Compared with a younger woman, a 70-year-old woman is five times more likely to sustain a hip fracture and three times more likely to incur any fracture during the rest of her life. The prevalence of trauma did not differ significantly among the main causes of syncope (cardiac, orthostatic hypotension, neurally mediated, and other causes including unknown origin). Thus, based on this finding, prevalence and the characteristics of syncope-related traumatic injuries do not add valuable information for elucidation of the specific cause of the symptom in patients referred to the ED for TLOC. Selecting patients referred to the ED threatens the external validity of the study and does not allow the findings to be generalized to the population at large. A study that only includes patients with syncope initially treated in an ED may overestimate the prevalence of secondary trauma in TLOC patients. Thus, the risk of traumatic injury associated with syncope might be much lower in the general population with TLOC. It has to be stressed that cardiac syncope can be a harbinger of sudden death. Because patients with this condition have a poor prognosis, with a 6-month mortality rate of .10%, timely and thorough evaluation is warranted. Among patients with severe syncope-related trauma, guidelines-based initial evaluation and further diagnostic work-up as appropriate resulted in a very high rate (.75%) of ‘definite’ diagnosis. Although assessment of this study subgroup (trauma patients) differed from that of previous trials that studied patients referred to the ED for syncope, this finding is surprisingly consistent with those of several prior studies. History and physical examination are the most specific and sensitive ways to evaluate syncope. The diagnosis is achieved with a thorough history and physical examination in up to 50% of patients. Additionally, electrocardiography should be performed in all patients since the presence or absence of heart disease offers