Syncope (peds)
For adult patients see syncope
Background
- Usually because of an abrupt cerebral hypoperfusion (30-50% from baseline)
- Peak age: 15-19 years of age
- In younger children, usually due to seizures, breath-holding spell or cardiac disease
Red flags
- Exercise-induced collapse
- Chest pain
- Previous cardiac surgery
- Family history of:
Clinical Features
- Abrupt loss of consciousness with full recovery after a short duration
Differential Diagnosis
- Seizure
- Toxicologic exposure (stimulants or depressant)
- CO poisoning
- Breath-holding spell
- Tet spell
- Cardiac disease
- Pregnancy (especially ectopic)
- Hypoglycemia
Syncope Causes
- Cardiovascular-mediated syncope
- Dysrhythmias:
- WPW (pre-excitation)
- Long QT Syndrome
- Brugada Syndrome
- Catecholaminergic polymorphic ventricular tachycardia
- 2nd/3rd AV Block
- Afib/aflutter
- Vtach/torsades
- Sick sinus syndrome
- Arrhythmogenic right ventricular dysplasia
- Short QT syndrome
- Cardiovascular disease
- Valvular Disease (AS, MS, tricuspid stenosis)
- Aortic Dissection
- Myocardial Infarction
- CHF
- Hypertrophic Cardiomyopathy
- PE
- Pericardial Tamponade
- Myxoma
- Pulmonary Hypertension
- Pacemaker malfunction
- Dysrhythmias:
- Neurally mediated syncope
- Vasovagal:
- Fear, pain, emotion, valsalva, breath-holding spell
- Situational (associated with):
- Vasovagal:
- Orthostatic hypotension-mediated syncope:
- Volume depletion:
- Dehydration (vomiting, diarrhea)
- Hemorrhage, (Ectopic Pregnancy, Upper GI Bleed/Lower GI Bleeding, Abdominal Aortic Aneurysm)
- Sepsis
- Autonomic Dysreflexia
- Autonomic failure due to meds
- Volume depletion:
- Other serious causes
- Stroke
- SAH
- TIA
- Vertebrobasilar Insufficiency
- Subclavian steal
- Heat syncope
- Hypoglycemia
- Hyperventilation
- Asphyxiation
- Seizure
- Narcolepsy
- Psychogenic (anxiety, conversion disorder, somatic symptom disorder)
- Toxic (drugs, carbon monoxide, etc.)
Evaluation
Workup
- ECG
- Urine pregnancy (if age/sex appropriate)
- Consider based on history/symptoms
- CBC (or POC hemoglobin) & chemistry (or POC glucose)
- TSH
- Tox screen (urine or serum – based on clinical scenario)
- Bedside cardiac echocardiography
- Cardiac hypertrophy or pericardial effusion
- Assess the IVC for dehydration
Diagnosis
- ECG may show:
- WPW – short PR, Delta waves, wide QRS
- Long QT syndrome – QTc >0.450 sec
- Hypertrophic cardiomyopathy – LVH, ST changes, T wave inversions, lateral leads needle like Q waves and absent R waves
- Brugada syndrome – incomplete RBBB with ST elevations in V1-3
- Arrhythmogenic right ventricular dysplasia (ARVD) – incomplete RBBB with T waves inversion in V1-3, epsilon wave is pathognomonic (up-notching of a terminal Q wave)
- Catecholaminergic polymorphic ventricular tachycardia - May present with VT/VF due to emotional stress or a regular ECG
Management
- Directed towards reversing the cause
Disposition
- Admission if any ECG abnormality found
- Admission usually not warranted – consider admitting kids with eating disorder
- Consider discharge home with cardiology consult and strict activity restrictions if suspicion of hypertrophic cardiomyopathy in otherwise well patient with reliable caretakers
See Also
References
- Fischer and Cho. Pediatric Syncope: cases from the ED. Emerg Med clin N Am. Vol 28. 2010. Pp 501-516.
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