Syncope (peds)

Background

• Usually because of an abrupt cerebral hypo-perfusion (30-50% from baseline)
• Peak age: 15-19 years of age
• In younger children, usually due to seizures, breath holding or cardiac disease

Red flags

• Exercise-induced collapse
• Chest pain
• Previous cardiac surgery
• Family history of:
  • Sudden Death
  • Cardiac disease at early age
  • Unexplained deaths
  • Death due to single-vehicle accident
  • Drowning
  • SIDS

Clinical Features

• Abrupt loss of consciousness with full recovery after a short duration

Differential Diagnosis

• Toxicological (stimulants or depressant)
• CO poisoning
• Breath-holding spell
• Tet spell
• Cardiac disease
• Pregnancy (especially ectopic)

Evaluation

• ECG – looking for:
  • 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
  • Bruagada syndrome – refer to Brugada (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 pathognemonic (up-notching of a terminal Q wave)

• Tox screen (urine or serum – based on clinical scenario)
• Beta-HCG
• Serum extended electrolytes, CBC, TSH
• Bedside cardiac ultrasound
  • Cardiac hypertrophy or pericardial effusion
  • Assess the IVC for dehydration

Management

• Directed towards reversing the cause

Disposition

• Admission if any ECG abnormality found
• Admission usually not warranted – consider admitting kids with eating disorder

See Also

• Syncope

References

• Fischer and Cho. Pediatric Syncope: cases from the ED. Emerg Med clin N Am. Vol 28. 2010. Pp 501-516.