Background
Syncope is a clinical syndrome in which transient loss of consciousness (LOC) is caused by a period of inadequate cerebral blood flow and oxygenation, most often the result of an abrupt drop of systemic blood pressure. Inadequate flow is typically of relatively brief duration, and is self-limited by definition. Syncope is a common presentation at music festivals (MFs), and is likely to be witnessed due to the population density at events.

Myoclonic Syncope vs Seizure
Syncope is often accompanied by involuntary, spontaneous myoclonic movements described incorrectly as seizures. A good example of these varied movements following induced orthostatic syncope, as well as the speed of recovery of consciousness, can be seen in this video. It is crucial to distinguish syncope from a true seizure based on clinical history; the duration of a patient's altered LOC is a key feature in this decision. If patients do not rapidly (<2 min) return to baseline, it is crucial to consider other causes of altered LOC.

Syncope at Music Festivals
Unlike the ED, the population attending MFs is typically young and healthy, without significant co-morbidities. Syncope in this population is usually due to environmental factors such as heat and dehydration or substance use. The true incidence of syncope at MFs is hard to estimate as it is often not distinguished from similar presentations. However, in publications, altered LOC typically represents 5-10% of all presentations and unpublished data suggest syncope is a common cause of LOC, 3.6% of all visits. Substances causing syncopal events include GHB, DMT and Alcohol. The evaluation of a “return to normal baseline” after a potential syncopal event may be complicated by underlying intoxication. However, syncope – even in young patients – can occasionally be a first presentation of rare but significant disease such as hypertrophic obstructive cardiomyopathy (HOCM), arrhythmia, pulmonary embolism (PE), ectopic pregnancy, or subarachnoid hemorrhage (SAH). It is crucial to rule out these and other concerning diagnoses.

History

• Features of syncope

  • Classic presyncopal prodrome

  • Expect myoclonic jerks

  • Time to return to baseline

• Absence of seizure features

• Triggers/Circumstances

• Frequency of episodes

Physical

• ABCs

• Trauma exam

  • Signs of head injury

  • Signs of fall trauma

• Cardiac Exam

• Neurologic exam

  • Pupils

  • Level of Consciousness

  • Focal neuro deficits

Investigations

• Glucose

• Orthostatic Vitals

• ECG

• Temperature

Figure 1 : Clinical Approach to Patient with Syncope at Music Festivals

Differential Diagnosis

• Dehydration

• Heat Stroke

• Intoxication (GHB common, with transient

  on-off-on pattern)

• Seizure (common mimic)

  PLUS usual ED rule-outs

  (rare in ED, and even rarer at MFs)

• Pulmonary Embolism

• Intracranial Bleed

• Hypertrophic Obstructive Cardiomyopathy

• Arrhythmias

• Metabolic (esp hypoglycemia)

• Carbon Monoxide Poisoning

RESOURCES // REFERENCES

Maleczek et al. Medical care at a mass gathering music festival : Retrospective study over 7 years (2011-2017). Wien Klin Wochenschr. 2022 Apr;134(7-8):324-331. PMID: 33900474. https://pubmed.ncbi.nlm.nih.gov/33900474/

Calle P, Sundahl N, Maudens K, Wille SM, Van Sassenbroeck D, De Graeve K, Gogaert S, De Paepe P, Devriese D, Arno G, Blanckaert P. Medical Emergencies Related to Ethanol and Illicit Drugs at an Annual, Nocturnal, Indoor, Electronic Dance Music Event. Prehosp Disaster Med. 2018 Feb;33(1):71-76. doi: 10.1017/S1049023X17007099. Epub 2017 Dec 29. PMID: 29284546. https://pubmed.ncbi.nlm.nih.gov/29284546/

Sinclair M, Pigott D. Texting shows recovery after faint. BMJ 2008;337:a2723
BMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a2723 (Published 18 December 2008)

Grange JT, Green SM, Downs W. Concert medicine: spectrum of medical problems encountered at 405 major concerts. Acad Emerg Med. 1999 Mar;6(3):202-7. doi: 10.1111/j.1553-2712.1999.tb00156.x. PMID: 10192671. https://pubmed.ncbi.nlm.nih.gov/10192671/

Kao, Wei-Fong & Kuo, C.-C & Hsu, Teh-Fu & Chang, Y.-Y & Chang, H. & Lee, Y.-L & Wu, J.-K & Lin, C.-S & Lee, F.-N & Sung, Y.-Y & Lee, Chen-Hsen. (2003). Fainting patients at a summer rock concert in year 2000. Tzu Chi Medical Journal. 15. 113-120.

Spaite DW, Meislin HW, Valenzuela TD, Criss EA, Smith R, Nelson A. Banning alcohol in a major college stadium: impact on the incidence and patterns of injury and illness. J Am Coll Health. 1990 Nov;39(3):125-8. doi: 10.1080/07448481.1990.9936223. PMID: 2246437. https://pubmed.ncbi.nlm.nih.gov/2246437/

Munn MB, Laraya JF. Altered Mental Status at Music Festivals: A Case Study Examining Clinical Concepts and Controversies. Prehosp Disaster Med. April 2017, 32(S1):S131-S132. DOI:10.1017/S1049023X17003673

Lempert T, Bauer M. Mass fainting at rock concerts. N Engl J Med. 1995 Jun 22;332(25):1721. doi: 10.1056/NEJM199506223322520. PMID: 7760886. https://pubmed.ncbi.nlm.nih.gov/7760886/

Morens DM. Mass fainting at medieval rock concerts. N Engl J Med. 1995 Nov 16;333(20):1361. doi: 10.1056/NEJM199511163332017. PMID: 7566046. https://pubmed.ncbi.nlm.nih.gov/7566046/