St Emlyn’s Lesson Plans
Syncope: a normal appearance is not the diagnosis
Reconstruct a blackout, identify concerning cardiac features and discuss monitoring, referral and advice.
New to Emergency Medicine / Induction / Early-career Emergency Medicine · 45-minute session
For learners
Before: Allow about 15 minutes in total.
When we meet: We will discuss an apparent trip in an older person and a collapse during exercise, including the ECG findings and interim advice.
Practise: use the practice card with a partner.
For facilitators
Send: the learner preparation link before teaching.
Bring: Use the NICE initial-assessment questions as the witness-history prompt and the verbal ECG findings in the cases. Appropriately licensed ECG images are optional.
Run: 45-minute session plan · 30-minute option
Practise: use the card for observed practice and feedback. Allow time for both turns, or arrange a follow-on practice session.
Before the session
If you are attending this session, complete the core preparation below before you come. Allow about 15 minutes in total.
Core preparation
NICE CG109: Transient loss of consciousness · About 12 minutes
Read CG109’s initial assessment, cardiovascular red flags, uncomplicated-faint criteria and driving advice. Note the questions you would ask a witness.
https://www.nice.org.uk/guidance/cg109/chapter/Recommendations
Think about (allow 3 minutes): What could a witness tell you that the patient may not be able to recall?
Picture the scene
The next patient is sitting up looking well. They say, “I only fainted—can I go home?”
By the end of the session
- Reconstruct the event using patient and witness accounts.
- Identify clinical and ECG features that need urgent cardiovascular assessment.
- Distinguish a plausible uncomplicated faint from unexplained or concerning transient loss of consciousness.
After the session
- In your next blackout assessment, record what happened before, during and after the event.
- Check whether your discharge documentation includes driving advice and who will provide follow-up.
Facilitator guide
Send learners the preparation link several days before teaching. Allow about 15 minutes in total.
Before learners arrive
- Confirm the local urgent syncope/cardiology route and monitoring facilities.
- Bring the current driving-advice resource and locally approved ECG examples with permission.
- Be prepared to explain postural BP assessment.
Equipment: Use the NICE initial-assessment questions as the witness-history prompt and the verbal ECG findings in the cases. Appropriately licensed ECG images are optional.
Setup: Use trios for a short witness-history call: clinician, witness and observer. The observer notes what remains uncertain. Then discuss the ECG findings and the interim plan before specialist review.
If the preparation has not been completed
Replace the witness-history and red-flag opening (12 minutes). Read the linked NICE initial-assessment and cardiovascular-red-flag sections for eight minutes. Spend four minutes in pairs rehearsing a witness history for the first case; use the questions in that guidance as the prompt card. For the 30-minute version, replace the five-minute witness-history opening with three minutes reading those sections and two minutes rehearsing the first questions.
Suggested session plan
- 0–5 min — Take the witness history. Ask for the first three witness questions.
- 5–12 min — Identify red flags. Use the NICE list to compare with learner suggestions.
- 12–35 min — Two cases. Have groups justify urgency and the interim safety plan.
- 35–40 min — Consolidate. Compare a concerning blackout with an uncomplicated faint.
- 40–45 min — Choose a follow-up action. Practise one clear advice statement.
Start the discussion
Read the opening scenario together. Give everyone a moment to think, then ask what concerns them and what they need to know next.
Cases and discussion
Use these cases, or invite an anonymised case from the group that addresses the same questions.
The fall may have been a blackout
An 80-year-old with facial injury says they tripped. They cannot describe the moment they fell.
Add this information as the discussion develops:
- A witness reports abrupt collapse without a clear trip. The ECG shows bifascicular conduction disease with PR prolongation.
Ask the group:
- What do you need from the witness?
- How does the ECG change urgency?
- What should happen while specialist assessment is organised?
Discussion notes
Points to draw out:
- Establish preceding symptoms, posture, colour, movements, duration and recovery; assess injury and other illness as well as the event.
- Conduction abnormality after possible syncope is concerning and requires prompt senior/cardiovascular assessment and appropriate monitoring.
- Describe the actual ECG findings rather than assuming the label “trifascicular block” proves the mechanism or a pacemaker indication.
Common misconceptions:
- Using the patient’s word “trip” as proof there was no loss of consciousness.
- Assuming facial injury alone diagnoses cardiac syncope.
For a more experienced group: Ask how current medicines and postural symptoms contribute without explaining away the abnormal ECG.
Collapse during exercise
A 35-year-old collapses while playing football and rapidly recovers. They recall palpitations beforehand.
Add this information as the discussion develops:
- A first-degree relative died suddenly when young; the ECG is abnormal.
Ask the group:
- Which facts prevent simple reassurance?
- What advice is needed while awaiting assessment?
- What can an ECG suggest without confirming?
Discussion notes
Points to draw out:
- Exertional loss of consciousness, concerning family history and ECG abnormalities need urgent cardiovascular assessment.
- Arrange a clear specialist plan and advise against driving pending specialist assessment in line with CG109/current DVLA requirements; address exercise and other safety risks individually.
- An ECG can raise concern for structural or electrical disease but does not on its own establish hypertrophic cardiomyopathy or device treatment.
Common misconceptions:
- Calling a quick recovery reassuring enough for discharge.
- Mistaking jerking during a faint as automatic proof of epilepsy.
For a more experienced group: Contrast with a clearly provoked uncomplicated faint and identify which features make that conclusion defensible.
Important clinical points
- High-risk cardiovascular features warrant urgent assessment; unstable patients need immediate treatment rather than an outpatient route.
- Do not use a brief convulsion or incontinence alone to diagnose epilepsy.
- Document driving and safety advice and consult the current DVLA guidance for licence-specific requirements.
Practise with a partner
Use the card to rehearse the skill together. One learner performs. One learner checks the key steps and gives feedback. Then swap roles.
Cardiovascular examination · FRCEM
Practise with a partnerRead the observer setup and allow time for both turns. Use the card alongside the lesson activity or in a follow-on practice session.
Closing the session
Use these questions to check what the group will take away. Go back over any clinical points that remain unclear.
- Why is a witness account useful when the patient feels well?
- Which ECG findings need urgent expert review?
- What makes a diagnosis of uncomplicated faint reasonable?
Key teaching points:
- Establish what happened before, during and after the loss of consciousness.
- Take the witness history and ECG seriously even when the patient has recovered.
- Include advice about driving and activity, and make the follow-up arrangements clear.
Before leaving, ask each person to choose one action from After the session and say when they will try it. They complete that follow-up in practice, with supervision where needed.
Adapting the discussion
Uncertainty and local practice
Some blackouts remain unexplained after ED assessment. Be explicit about uncertainty and the specialist plan rather than forcing a label.
If the discussion drifts
Which feature would make reassurance unsafe?
For a more experienced group
Explore the limits of syncope risk scores, ambulatory monitoring options and distinction between a suggestive ECG and a confirmed mechanism.
A 30-minute version
30 minutes: witness history 5; older-person case 10; exertional case 10; consolidation and reflection 5. Omit the extended ECG teaching.
Evidence and guidance
- NICE CG109: Transient loss of consciousness — Updated 2023: history, ECG, red flags, referral and driving advice.https://www.nice.org.uk/guidance/cg109/chapter/Recommendations
Suggested curriculum links
RCEM 2021 curriculum (2025 update): SLO1 Care for physiologically stable adults with acute presentations
Safe assessment, differential diagnosis and disposition.
Check these links against the learner’s stage and programme. Attendance at a teaching session does not establish competence.
First published 2020-06-06 · Iain Beardsell.