An Extensive Syncopal Workup for Geriatric Patients After a Traumatic Fall: Is It Worth It?

Identifying the cause of syncope in geriatric patients presenting with syncope causing a traumatic fall is challenging in the absence of well-established guidelines. We hypothesize that most of the geriatric inpatient syncopal workup, including transthoracic echocardiogram and carotid duplex, is excessive and can be safely abandoned.  Methods: A retrospective review of data collected on 134 patients from Conemaugh Memorial Hospital, a single-level I trauma hospital in Johnstown, Pennsylvania, from January 2017 to October 2021 was carried out. Patients ≥65 years old, with a diagnosis of syncope and fall with a Glasgow Coma Scale ≥14, were included. Demographics, initial inpatient syncopal workup, including cardiac monitor, electrocardiogram, cardiac enzymes, orthostatic vitals, transthoracic echocardiogram, carotid duplex ultrasound, and thyroid-stimulating hormone levels, were recorded. Intervention, including Holter monitoring, cardiac catheterization, or implantation of a defibrillator, was also captured. Measurement of outcomes was presented as counts and percentages.  Results: A total of 747 studies were done for 134 patients, out of which 17 studies (2.3%) for 9% (12/134) of patients had positive findings. This translated into 6% (8/134) of patients requiring a change in treatment based on those findings.  Discussion: Based on our results, most causes of syncope can be diagnosed with cardiac monitoring and an ECG. Cardiac monitoring and an electrocardiogram were most likely to yield a positive finding. Further testing with transthoracic echocardiogram (TTE) or carotid duplex can be safely performed on a case-by-case, outpatient basis.

Syncopal workup should be ordered based on the initial assessment, review of the pre-hospital medications, and ECG findings. ​Additional testing can be performed on a case-by-case, outpatient basis, depending on the physician's discretion for more efficient care and a reduction in healthcare expenditure.