Syncope in Children and Adolescents
Syncope is a fairly common complaint in the peds ED. It typically presents more often in older children and teens than in younger kids, and the most common cause is benign and vasovagal. Syncope is one of those complaints in which the patient may be completely back to baseline by the time they even arrive. However, obtaining a thorough history and complete work-up is vital, as there can be life-threatening causes to a syncopal episode.
History
Events prior to episode
Food or drinks or lack there of, activity before episode, exercise before or during, medications taken, drug or alcohol ingestion, anxiety over stressful situations, or trauma
Preceding symptoms
Confusion, lightheadedness, vision change/”tunnel vision”, sweating/clamminess, chest pain, palpitations, shortness of breath, dizziness, or presence of inappropriate scents
Following symptoms
Incontinence, vomiting, or continued presence of symptoms listed above
Length of LOC and length it took for patient to return to baseline
If the episode was witnessed by anyone, and if so what their account of the episode is
Patient history of previous syncopal episodes
Any trauma secondary to syncope (ex: a fall onto the ground and suffering head trauma)
Personal and family hx of neurological disorders
Seizures or migraines
Personal and family hx of cardiovascular disorders
Arrhythmia, hypertension, congenital heart disease, sudden cardiac death
Physical Exam
Cardiovascular
Patients may be slightly bradycardic, but otherwise normal
Respiratory (because you do it on everyone!)
Skin
Assess if patient is cool, clammy, flushed, or pale
Full neuro exam
Including a basic mental status assessment can’t hurt, such as asking what holiday is coming up, a favorite school teacher’s name, or the patient’s birthday
Any areas of trauma
Ex: assessing for laceration, bruising, or hematoma if the patient suffered a CHI
Work Up
EKG
Cardiovascular pathology must be ruled out
D-stick glucose
Hypoglycemia is a common cause of vasovagal syncope
Chest XR
Rule out cardiomegaly
Urine HCG
Obviously only for female adolescents
Urine toxicology
Typically reserved for adolescents
Fluids (PO highly preferred)
Dehydration is another common cause
Possible trauma evaluation
Ex: hand and wrist XR if patient fell onto hand, head CT w/o contrast if patent suffered a CHI and continues to have confusion
As mentioned, vasovagal syncope is the most common presentation and patients can typically be discharged after a normal work up is obtained and a correctable cause is identified and treated. However, if the patient has an abnormal EKG or CXR, cardiology should be consulted. At this point, further workup, including cardiac enzymes, CBC, and BMP, and evaluation by a cardiologist may be warranted.