ROSE (Risk Stratification of Syncope in the Emergency Department) Rule

Why Use

Syncope is a common, potentially serious condition accounting for many hospital admissions. This tool helps distinguish benign syncope from syncope signaling life-threatening disease, guiding evaluation and disposition.

When to Use

Use in patients ≥16 years old presenting to the emergency department with true acute syncope to help identify patients at risk for life-threatening conditions.

Formula

Pearls / Pitfalls

Highlights high-yield red flags associated with life-threatening conditions. Should not be used in patients with: Presyncope. Persistent neurological deficits (e.g., stroke). Intoxication (e.g., alcohol). Hypoglycemia. Trauma. Seizure activity >15 minutes with witnessed postictal phase. In the derivation/validation cohorts, any positive item yielded a sensitivity ~87% and NPV ~98.5% for 30-day serious outcomes.

Management

Any criterion present: Admit or observe with continuous monitoring and pursue a targeted evaluation based on signs, symptoms, and initial workup. No criteria present: If the overall presentation is reassuring (e.g., normal vitals, no structural heart disease), consider discharge with prompt outpatient follow-up, education, and clear return precautions. If clinical concern remains, consider admission and further workup.

Advice

As with all clinical decision rules, do not base management solely on this score; correlate with clinical judgment. Any one positive ROSE criterion classifies the patient as high risk for 30-day serious outcome or all-cause death.