Urgent Care · Common Complaints
Dizziness / Syncope
Cardiac syncope is deadly — and the first task in urgent care is to separate vertigo, presyncope, syncope, and disequilibrium because they have very different workups. This page covers the can't-miss diagnoses (cardiac syncope from arrhythmia or structural heart disease, aortic stenosis, pulmonary embolism, posterior circulation stroke, GI bleed, aortic dissection, hypoglycemia, sepsis, severe anemia), red flags including syncope without prodrome or during exertion and abnormal ECG findings, the minimum safe first-pass workup (focused history, orthostatic vitals, ECG on every syncope, neuro exam, HEENT for BPPV, POC glucose), risk stratification with San Francisco Syncope Rule, outpatient management of benign causes, escalation criteria, documentation, and return precautions. Written for NPs, PAs, and MDs in outpatient practice.
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Urgent Care · Common Complaints
Dizziness / Syncope
Why this symptom matters
Cardiac syncope is deadly. The first task is to separate vertigo, presyncope, syncope, and disequilibrium — they have very different workups.
What must I not miss first?
- Cardiac syncope (arrhythmia, structural heart disease, AS)
- Pulmonary embolism
- Posterior circulation stroke
- GI bleed
- Aortic dissection
- Hypoglycemia
- Sepsis
- Severe anemia
Red flags — escalate or work up urgently
- Syncope without prodrome or during exertion
- Family history of sudden cardiac death
- Abnormal ECG, palpitations, chest pain
- Focal neuro deficit, dysarthria, ataxia, diplopia
- Persistent vertigo with unsteady gait — cannot stand or walk without falling
- Hypotension, tachycardia, melena/hematemesis
- Anticoagulated patient with syncope
Immediate Management — While You Work It Up
- Supine position immediately — do not allow patient to walk unassisted under any circumstances.
- IV access and cardiac monitor — syncope is cardiac until proven otherwise.
- 12-lead ECG — within 10 minutes. Look for long QT, heart block, Brugada, delta waves, and ST changes.
- Orthostatic vitals — measure BP and HR lying, sitting, and standing. A drop in SBP > 20 or HR rise > 20 is significant.
- Fingerstick glucose — hypoglycemia presents as syncope and dizziness, especially in older adults and diabetic patients.
- IV fluids — if orthostatic hypotension or clinical dehydration is present.
- Do not discharge syncope without a clear benign etiology — vasovagal requires documentation of precipitating factors, prodrome, and full recovery.
Minimum safe first-pass workup
- What to ask: true LOC vs. near-syncope vs. spinning, position dependence, prodrome, exertion, palpitations, prior cardiac history, medications (BP meds, antiarrhythmics, hypoglycemics)
- What to examine: orthostatics, full cardiac exam (rate/rhythm/murmurs), neuro exam (especially cerebellar — gait, finger-nose, heel-shin), HINTS exam if acute vestibular syndrome
- ECG on every syncope
- POC glucose, hemoglobin if available
- Pregnancy test if applicable
What can usually be managed outpatient
- Vasovagal syncope with classic prodrome and reassuring workup
- BPPV with positive Dix-Hallpike, no central signs — Epley in clinic
- Orthostatic hypotension from a clear medication or volume cause, corrected in clinic
- Recurrent known vestibular neuritis with prior diagnosis, no new red flags
When to escalate to ED / higher level of care
- Any concerning ECG (long QT, AV block, ischemia, Brugada, WPW, new BBB)
- Exertional syncope or syncope without prodrome
- Posterior circulation signs — even subtle
- HINTS exam concerning for central cause
- Suspected PE, GI bleed, sepsis, dissection
- Older adult with first-ever syncope
What to document when the diagnosis is still uncertain
- Type of dizziness in patient's words; loss of consciousness yes/no
- Triggers, prodrome, post-event symptoms
- ECG findings, orthostatics, neuro exam (cerebellar specifically)
- "Cardiac syncope / posterior stroke / PE / GI bleed considered because… ruled out today because…"
- Driving counseling if applicable; discharge vitals; return precautions
Safety-net & return precautions to give
- Return or call 911 for chest pain, palpitations, weakness, slurred speech, vision change, severe headache, black/bloody stools, or another fainting episode.
- Avoid driving until cleared, especially after unexplained syncope.
- Follow up with PCP / cardiology as directed within 24–72 hours.
Geriatric-specific modifiers (apply on top of the above)
The guidance above applies to all adult patients seen in this setting. Layer the points below for adults 55+, geriatric (65+), and frail younger adults — they are additions, not replacements.
Dizziness in older adults is high-risk because it is rarely "just dizziness." Many older patients describe "I feel off," "woozy," "like I might fall" rather than true spinning vertigo — and the underlying cause is more often cardiac, medication-related, or stroke than vestibular.
- Always check orthostatic vitals in older adults with dizziness — orthostatic hypotension from dehydration, antihypertensives, diuretics, alpha-blockers, and tamsulosin is one of the most common (and reversible) causes.
- Do an ECG on every older adult with dizziness or near-syncope — bradyarrhythmias, AV block, and silent AFib are common.
- Lower threshold for posterior circulation stroke workup — even mild gait ataxia, diplopia, or new dysarthria warrants ED transfer. Use HINTS exam if you are trained in it.
- Polypharmacy is the most common driver: review benzodiazepines, opioids, anticholinergics, antihypertensives, sedating antihistamines, gabapentinoids, and recent dose changes.
- Avoid meclizine and first-generation antihistamines for chronic dizziness — Beers-listed, increase falls and delirium.
- Hypoglycemia mimics dizziness, especially in diabetics on insulin or sulfonylureas — always check glucose.
- Consider sepsis, anemia, and dehydration as quiet drivers — fever and tachycardia may be blunted by beta-blockers.
- An older adult with first-ever syncope is high-risk by default — strongly consider ED for telemetry and workup.
Educational guidance for clinicians. Not a substitute for clinical judgment. Always individualize to the patient and your local resources.
Evidence sources
- · AHA/ACC/HRS Syncope Guideline 2017
- · AAO-HNS BPPV Guideline 2017
- · AGS Beers Criteria
- · AGS Geriatric ED Guidelines
Review status
Last reviewed: 2026-04
Reviewed by the MyClinicianGuide editorial team. Cadence: annual.
Educational reference for licensed clinicians (NP, PA, MD, DO). Not a substitute for clinical judgment, institutional protocols, or specialty consultation. Apply in context of the full clinical picture, patient goals, and current standards of care. See About AI guidance for AI-related limitations.
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