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c high risk 12 Lead EKG (even in the young for prolonged QT and Brugada), consider CBC or guiac and pregnancy test.Admit high risk or young pts c syncope during exercise (ACEP Clinical Guidelines) Neurally Mediated Syncope associated with inappropriate vasodilatation, bradycardia or both. Vasovagal syncope is often associated with a sensation of increased warmth and may be accompanied by nausea.It may occur after exposure to an unexpected or unpleasant sight, sound or smell, fear, severe pain, emotional distress and instrumentation.It may also occur in association with prolonged standing or kneeling in a crowded or warm place or on exertion (all three latter scenarios may also be due to autonomic failure) b.Situational syncope occurs during or immediately after coughing, micturition, defecation or swallowing.

Syncope associated with throat or facial pain, however, may be due to glossopharyngeal or trigeminal neuralgia c.

Carotid sinus syncope can be associated with neck pressure (shaving, tight collar) or head turning Orthostatic Syncope Occurs when there is documented hypotension associated with syncopal or presyncopal symptoms.

According to ECS guidelines, orthostatic blood pressures are recommended to be taken after five minutes of being supine.

A decrease of more than 20mm Hg in the systolic pressure is considered abnormal as is a drop in pressure below 90mm Hg independent of the development of symptoms.

Neurologic Syncope Neurologic causes of apparent syncope include seizures, TIAs, migraine headaches and subclavian steal syndrome.

Confusion after “syncope” that lasts more than five minutes, tongue biting, incontinence, epileptic aura suggest this diagnosis.