Pediatric Primary Care Case Studies, 1st Ed.

Chapter 23. The Athlete Who Experienced Syncope

Patrick E. Killeen

An episode of syncope in a child or adolescent always merits careful investigation by the primary care provider (PCP). The clinical question that must be quickly answered when the child or teen is first seen is whether the syncopal event (or events) represents a serious underlying medical problem or a non-life-threatening, temporary annoyance. The PCP must obtain a detailed history to accurately identify the underlying cause of a particular child’s syncope from the wide range of potential differential diagnoses associated with syncopal events. Omission of key questions may result in unnecessary and expensive diagnostic testing or failure to identify an underlying life-threatening medical problem. After having adequately explored essential historical questions and queried for significant associated symptoms with the child or teen and/or parent(s), a thorough physical examination is then performed. In addition to outlining history and physical findings that are critical elements of the assessment, this case study will also feature information about the often challenging issue of selecting diagnostic tests that should be ordered routinely or based on symptomatology and when to refer the child to a specialist for a definitive diagnosis or additional diagnostic work-up and management.

Educational Objectives

1.  Identify key historical questions that need to be asked when a teen has experienced a syncopal episode.

2.  Differentiate between signs and symptoms that point to a life-threatening syncopal condition versus a benign syncopal event.

3.  Understand the underlying mechanisms of vasovagal-induced syncope.

4.  Describe the key principles underlying the emergent evaluation of syncope in children and adolescents.

5.  Identify the initial screening diagnostic work-up for a female teen who presents in the emergency department (ED) with a first-time episode of syncope.

 Case Presentation and Discussion

Emma Kaplan is a 14-year-old female who “fainted” after a field hockey game. Emma arrives with her field hockey coach to the ED via ambulance. She is alert and conscious. The coach states that immediately after the game while all the girls were in a huddle Emma “stood up and passed out.” The coach states that Emma fell face down and was unresponsive for about 15–30 seconds or so. Emma states that she remembers playing the entire game while feeling hot, nauseated, sweaty, and short of breath. The last thing she remembers is suddenly feeling dizzy.

Before you proceed further, you need to review what you know about syncope episodes.

Overview of Syncope

Syncope is a sudden, brief loss of consciousness associated with loss of postural tone from which recovery is spontaneous (Kapoor, 2000). This abrupt loss of consciousness results from an interruption of energy sources to the brain, usually because of a sudden reduction of cerebral perfusion. Up to 15% of children experience a syncopal episode prior to the end of adolescence (Lewis & Dhala, 1999). Life-threatening causes of syncope can be identified by a detailed history and physical examination including family history and a few select diagnostic studies. There are multiple causes of syncope for the practitioner to consider, some of which may be life-threatening. (See Table 23-1.) Their origin can be:

•  Neurologic

image  Seizure/migraine syndrome

image  Cerebral concussion

•  Cardiac

image  Cardiac arrhythmias including long QT syndrome

image  Vasovagal

•  Pregnancy

•  Psychogenic

image  Hyperventilation or breath holding

image  Hysteria (somatization disorder) or a conversion disorder

•  Medications or illicit drugs including antidepressant drugs

•  Dehydration/volume depletion

•  Toxins, e.g., carbon monoxide poisoning, inhalant/huffing

Etiology of Syncope

There are multiple causes of syncope that the healthcare provider must consider as part of the differential diagnoses of syncope. Some conditions are life-threatening whereas others are benign. Thus, the challenge for the primary care provider is to correctly distinguish a benign cause from a life-threatening problem, and to do so in a cost-effective manner without ordering unnecessary and costly diagnostic tests. When life-threatening etiologies are identified, the responsibility of the primary care provider is to quickly refer the child or adolescent to the appropriate specialist. Table 23-1 lists causes of syncope in children from which to establish a list of differential diagnoses you will need to consider in Emma’s situation.

Table 23–1 Causes of Syncope in Childrena

Primary electrical disturbances:

 

Long QT syndrome

 

Brugada syndrome

 

Familial catecholaminergic polymorphic ventricular tachycardia

 

Short QT syndrome

 

Preexcitation syndromes (such as Wolff-Parkinson-White)

 

Bradyarrhythmias (complete atrioventricular block, sinus node dysfunction)

 

Structural abnormalities:

 

Hypertrophic cardiomyopathy

 

Coronary artery anomalies

 

Arrhythmogenic right ventricular dysplasia/cardiomyopathy

 

Valvar aortic stenosis

 

Dilated cardiomyopathy

 

Pulmonary hypertension

 

Acute myocarditis

 

Congenital heart disease

 

Other causes:

 

Vasovagal (neurocardiogenic) syndrome, including situational syncope (cough, micturation, hair combing)

 

Breath-holding spell

 

Orthostatic hypotension (hemorrhage, dehydration, pregnancy)

 

Toxic exposure

 

Hypoglycemia

 

Conditions that may mimic syncope:

 

Seizure

 

Migraine syndromes

 

Hysterical faint

 

Hyperventilation

 

aCauses listed in bold are serious or life-threatening. Causes listed in italic are common.

 

Source:© 2008 UpToDate.


 

Benign Causes of Syncope

The majority of causes of pediatric syncopal episodes are benign changes in vasomotor tone (Massin et al., 2004) such as breath holding and orthostatic hypotension. Other conditions that imitate syncope are overdose, drugs, seizures, migraine syndromes, hysteria, hyperventilation, and pregnancy.

Neurocardiogenic Syncope

Neurocardiogenic syncope (vasovagal) is a neurally mediated disorder and a common cause of syncope. Children with neurocardiogenic (vasovagal) syncope frequently report symptoms before the event that include dizziness, lightheadedness, sweating, nausea, weakness, and visual changes (blurred vision, tunnel vision, slow visual loss). Patients with orthostatic hypotension or vasovagal syncope may report that symptoms recurred when they tried to sit up immediately after the initial syncopal event. The duration of such activity is usually brief and recovery is rapid. In comparison, prolonged motor activity or postictal recovery time are consistent with a seizure (Reuter & Brownstein, 2002).

Children with a neurocardiogenic/vasovagal cause of syncope typically have been upright or changed position just prior to the event. A trigger such as pain or stress may be the precipitant in some cases. Syncope that occurs during physical exertion is very concerning for a cardiac etiology, whereas syncope after exertion may occur with neurocardiogenic/vasovagal syncope or cardiac conditions (Driscoll, Jacobsen, Porter, & Wollan, 1997; Massin et al., 2004). In a 2001 study reviewing recurrent syncope, neurocardiogenic/vasovagal syncope was considered the cause in 35% of such events (Mathias, Deguchi, & Schatz, 2001). However, neurocardiogenic/vasovagal syncope remains a diagnosis of exclusion.

The diagnosis can also be made by exclusion of other causes of syncope and by a characteristic response to upright tilt table testing, during which the patient may pass out from bradycardia and/or hypotension. These patients do not necessarily require treatment.

Seizure

Seizure refers to a transient occurrence of signs and/or symptoms due to excessive neuronal activity of the brain. Abnormal movement such as tonic clonic movement can occur. The duration of such activity is usually brief and recovery is rapid. Prolonged abnormal movements and/or prolonged recovery time are consistent with a seizure, as are loss of bowel or bladder control. In the patient with prolonged loss of consciousness, seizure activity, or a postictal phase, a routine outpatient electroencephalogram (EEG) or 24-hour video EEG should be considered. Neuroimaging may be indicated emergently for children with focal neurologic deficits, persistently altered mental status, or a significant head injury as a result of the syncopal episode. Syncope is distinguished from seizures by accompanying pallor, prodromal lightheadedness and visual changes, lack of postictal state, and no loss of bowel or bladder control.

Cardiac Causes

Cardiac issues that cause syncope can be life-threatening. Shortness of breath, chest pain, or palpitations prior to or during the event are concerning for a cardiac etiology. Sudden death in the young athlete occurs with an estimated prevalence of between 1:100,000 and 1:300,000 (Maron et al., 1996).

Cardiac issues that cause syncope are primary electrical disturbances and structural heart disease including exercise-related syncope. As stated earlier, syncope that occurs during physical exertion is very concerning for a cardiac etiology, whereas syncope after exertion may occur with vasovagal syncope or cardiac conditions (Driscoll et al., 1997; Massin et al., 2004). This is a major point that must always be considered.

One specific primary electrical disturbance that is worrisome is long QT syndrome. Triggers include a sudden startle or even auditory stimuli such as a fire alarm (Moss, 2003). An electrocardiogram (ECG) is considered a standard part of the syncope work-up. A patient with a normal ECG has a low likelihood of arrhythmia as a cause of syncope (Kapoor, 2000). ECG abnormalities may be variable and/or subtle, thus a cardiologist consult should be considered whenever there are incongruent clinical features, regardless of the ECG findings.

ECG findings consistent with life threatening causes of syncope that should be noted include:

•  Bradycardia or atrioventricular block

•  Prolonged QT interval/short QT interval (less than or equal to 0.30 seconds)

•  Brugada pattern/pseudo right bundle branch block with ST elevation in leads V1 to V3

•  Epsilon waves (arrhythmogenic right ventricular dysplasia)

•  Preexcitation syndrome (Wolff-Parkinson-White)

•  Nonsinus rhythm

•  Signs of myocardial injury

•  Ventricular hypertrophy or strain patterns

Recurrent syncope can be attributed to both psychogenic and cardiac etiologies. In a review of 433 patients, the cumulative incidence of recurrence of syncope at 3 years was 31% for patients with a cardiovascular etiology, 36% for those with a noncardiovascular cause, and 43% for those with syncope of unknown etiology (Kapoor et al., 1987).

What information do you need to evaluate Emma’s fainting spell? image

Historical Data Necessary for Syncope Analysis in Children

The first area to investigate relates to the specific facts about the situation immediately preceding the event. This includes a detailed description of the child’s position and the activity the child was participating in prior to the syncopal episode. For example, if the child was in a seated position and then stood up and fainted, such syncope may be considered benign vasovagal or postural hypotension. In contrast, if the child was in full stride at a field hockey game and collapsed, this could indicate a life-threatening cardiac event. When asking for a description of the event, obtain the child’s self-report of symptoms prior to the onset of syncope as well as witnesses’ description of the syncopal event.

Here are a few suggested questions to ask:

•  Did the child or adolescent feel dizzy or experience lightheadedness, sweating, nausea, weakness, numbness in hands or feet, and visual changes?

•  Did the witness observe rapid breathing or emotional stress that may be indicative of hyperventilation or induced syncope?

Positive answers to these questions are consistent with a benign cause. Seek information about whether abnormal movements such as tonic clonic movements or focal movement of one extremity were noted, including the length of the time frame surrounding the abnormal activity, approximate length of loss of consciousness, and loss of bowel or bladder control with the syncopal episode. Positive findings would be consistent with a seizure.

For the child with a history of collapsing and being unresponsive, ask whether cardiopulmonary resuscitation was administered and/or whether an automated external defibrillator was used. If this is the case, obtain a detailed history of the sequence of basic life support interventions.

If a healthcare provider witnesses a syncopal event in a child or adolescent, there are a few additional assessment points to remember. During and immediately after the syncopal event, check for brady-or tachy-arrhythmias, check blood pressure for hypotension, and look for signs and symptoms of dehydration; all could be clinical symptoms and indicators of decreased perfusion. Observe for hyperventilation and ask about numbness of extremities or fingers or toes. If hyperventilation and numbness are consistent with the event, consider a diagnosis of hyperventilation-induced syncope or a conversion disorder.

Red flags that indicate a cardiac evaluation is needed include the following family issues: a family history of early cardiac death (less than 45 years of age), sudden deaths including unexplained accidents involving a single motor vehicle or drowning, known arrhythmia (long QT syndrome), and familial cardiomyopathy. If positive, any of these factors increases the concern for a cardiac etiology (Gillette & Garson, 1992). A family history may be present in up to 90% of children with vasovagal syncope (Reuter & Brownstein, 2002). A review of the past medical history of congenital heart disease or arrhythmia may focus attention on a potential cardiac etiology. Previous syncopal events suggest a vasovagal, psychogenic cause, or a cardiac etiology.

Other elements of the history should include questioning about the following:

•  Presence of underlying medical problems (such as diabetes or cardiac history).

•  Menstrual history—did the event occur while menstruating, cramping, or a heavy period with clotting?

•  Access to and use of medications or illicit drugs.

•  Prolonged loss of consciousness or unconscious for more than several seconds with a postictal period. If this occurs, the child should be evaluated for a neurologic disorder, such as a seizure or migraine syndrome.

•  Transient loss of consciousness for less than several seconds in a child with a normal ECG and cardiac examination. This most likely represents noncardiac syncope.

•  Typical characteristics of vasovagal-induced syncope. Vasovagal syncope is a neurocardiogenic incident that is usually diagnosed on clinical features. The absence of a significant prodrome, associated palpitations or chest pain, or a family history of syncope or sudden death may require further cardiac evaluation.

•  Orthostatic hypotension. This is the likely etiology for syncope in patients with postural changes in heart rate and blood pressure and a normal ECG. The underlying cause of these changes such as dehydration/ volume depletion should be identified and treated. Although orthostatic hypotension has also been associated with long QT syndrome, the ECG is abnormal in the vast majority of cases (Atkins, Hanusa, Sefcik, & Kapoor, 1991).

•  A toxic exposure may be suggested by history such as the use of inhalants/huffing or identified by a urine toxicologic screen for medications or illicit drugs including antidepressant drugs or carbon monoxide poisoning.

•  Hyperventilation-induced syncope. This demonstrates an abnormal respiratory pattern prior to the syncopal episode and is commonly seen in adolescents experiencing some type of emotional stress. They may describe additional symptoms such as chest pain, lightheadedness, paresthesias/numbness in hands or feet, and visual disturbances.

•  Breath-holding spells occur in younger children (6 to 24 months). In this case, syncope develops in association with breath holding. A cardiac evaluation is indicated for children with a family history of syncope or sudden death or with episodes that are prolonged, frequent, or precipitated by startle or other nontraumatic stimuli.

•  Somatization disorder/hysteria or a conversion disorder. This commonly occurs in adolescents. Expected physiologic signs of syncope such as sweating, pallor, or changes in heart rate and blood pressure are absent. In addition, patients may disclose details of the event that indicate no loss of consciousness and generally suffer no injury during collapse.

•  Choking games in which an adolescent purposely attempts self-strangulation or allows strangulation by another person with the hands or a ligature. The goal of the game is to reach a euphoric state created by the hypoxia, and then release the pressure just before loss of consciousness. Failure to do so can result in death.

•  Vasovagal (neurocardiogenic) syncope is a diagnosis of exclusion for patients with consistent clinical features.

Using the above information, what other history questions do you need to ask Emma and her mother? image

Other questions that are an important consideration as part of your symptom analysis include:

•  Did she have any posturing or shaking of her body or seizure-like activity?

•  Did she experience flashing lights, stars, blind spots, or doubled or blurred vision?

•  Is there a history of headaches, numbness, or tingling?

•  Did anyone notice the color of her skin? Was it pink, blue, or mottled?

•  Has she experienced any recent trauma?

•  Were there palpitations or chest pain associated with the syncope?

•  Did she have shortness of breath?

•  Has she had fever or weight loss or complaints of tiredness or fatigue?

•  What, if any, medication (or medications) is she taking including over-the-counter drugs, herbal or nutritional supplements, and antidepressant drugs?

Emma’s mother, Mrs. Kaplan, has now arrived at the ED and together they provide you with the following information: Mrs. Kaplan reports that Emma has been very healthy. She has never been hospitalized or in the ED before. Her immunizations are up to date, and she has no food or medication allergies and takes no medication or nutritional supplements. She has never passed out before nor does she have a history of recent trauma, headaches, or a heart problem. She has not had a fever, weight loss, or complaints of tiredness or fatigue.

Emma has always been a “B” student and is now attending a new school after Mrs. Kaplan’s recent divorce. Mrs. Kaplan states Emma has adjusted well to the recent divorce and she has made many new friends in a short time in her new school. She feels Emma’s school performance continues to improve. Emma’s last menstrual period was 2 weeks ago and described as a normal 5-day flow. She states she uses pads (not tampons) for her periods.

In the absence of her mother and coach, Emma denies any illicit drug, inhalant/ huffing, and medication use. Emma states that it was a tough field hockey game against the Ridgefield Ravens. This was her first game playing with her new teammates, and she felt she had to prove to the other girls she was a great team player. She focused on making great passes and assists to make each team point. She denies chest pain or shortness of breath, and it seemed she was running more than usual and was very hot and sweaty. Emma recalls the events prior to her passing out and states when the team completed the huddle at the end of the game, she stood up and suddenly felt lightheaded, nauseous, and then things got blurry. The next thing she remembers is waking up, with one of her classmates holding her legs up and the coach asking her to tell him what happened.

You talk to Emma’s coach. He states that there was no trauma during the game, and that at the end of the game, after the huddle, Emma “stood up and passed out.” Emma fell face down and was unresponsive for about 15–30 seconds or so. Emma had no jerking movements, no color changes, and no loss of bowel or bladder control. When she came to, she seemed surprised she was on the ground and has seemed normal ever since.

In considering whether this syncopal episode could have resulted from an underlying life-threatening cardiac issue, you must quickly collect information from Emma and her mother and document their answers about the following key issues:

•  Did the syncope occur during activity/exertion?

•  Is there a family history of early cardiac death?

•  Does Emma have a history of congenital heart disease?

•  Is her past medical history significant for cardiac disease or risk factors (e.g., elevated blood pressure, supraventricular tachycardia, anorexia nervosa)?

From your interviews with Emma, her mother, and her coach, you know that Emma’s syncope took place after the game, and you have also been given assurance that there is no family history of early cardiac death nor does Emma have congenital heart disease or arrhythmias or a history of anorexia or blood pressure problems.

What would be your next plan of action? image

Based on Emma’s presenting symptoms, you ask the ED nurse to draw a standard blood panel including complete blood count, chemistry, toxicology, and pregnancy test. You look up at the cardiac monitor and note that she is in normal sinus rhythm. You are now ready to begin your physical examination of Emma.

Physical Examination

The healthcare provider should perform a complete physical exam that includes full vital signs including orthostatic pulse and blood pressure measurements and cardiac and neurologic examinations.

Abnormal blood pressures include a decrease in systolic blood pressure by 20 mm Hg or an increase in heart rate by 20 beats per minute from sitting to standing. More significant than changes in blood pressure is the recurrence of symptoms such as lightheadedness or syncope on standing. However, the presence of orthostatic hypotension does not rule out other causes of syncope, particularly long QT syndrome (Atkins et al., 1991). An age-appropriate neurologic exam should be performed to identify focal deficits or seizures.

Emma’s vital signs reveal blood pressure (BP) 110/60, temperature 97.9°F, pulse 70, respirations 18, and pulse oximetry 98%. Orthostatic BPs are as follows: sitting 110/60 and standing 102/55. Heart rate: sitting 70 and standing 78. Her four-point BPs lying down are: right arm 110/60; left arm 118/64; right leg 100/55; left leg 100/56. General appearance is that of an alert, oriented, well-developed, and well-nourished 14-year-old who is holding her mother’s hand. You perform a thorough cardiac and neurologic examination of Emma. The cardiovascular exam reveals a regular rate and rhythm, normal S1 and S2, and no cardiac gallop, rub, or murmur including with a Valsalva maneuver and squatting. There is no carotid bruit, jugular venous distention, or peripheral edema. She has strong distal pulses with warm extremities and her capillary refill is less than 2 seconds. Her liver is at the right costal margin without hepatomegaly. The neurologic exam reveals full recall of all incidents before and after her syncopal event. She is alert and oriented to person, place, and time. Her cranial nerves II-XII are intact; she has symmetric bilateral deep tendon reflexes, with good muscle tone and strength, and has a normal gait and stance. The remaining findings of her physical exam are likewise unremarkable.

Children and adolescents, like Emma, with a normal ECG and cardiac examination are unlikely to have a cardiac etiology. However, a change in cardiac exam with evidence of new heart sounds, including gallops, rubs, and murmurs, may suggest the following structural lesions:

•  Aortic stenosis is associated with a systolic ejection murmur and ejection click.

•  Valvar stenosis may be associated with coarctation of the aorta. Four extremity blood pressures should be recorded. A difference in the systolic measurement of 20 mm Hg in the arm greater than in the legs is significant.

•  Hypertrophic cardiomyopathy causes a murmur that is heard best during a Valsalva maneuver or squatting.

•  New onset congestive heart failure may be diagnosed if findings such as rales, a gallop, and hepatomegaly, not noted before, are now evident on examination.

What laboratory tests did you need to order and what were the results? image

Here are the initial laboratory studies and data that are important to help you determine the probability of potential differential diagnoses related to the cause of Emma’s syncopal episode and to assist you in developing a management plan.

Blood studies with normal values indicated in parentheses:

image  Na (sodium): 145 (136–146 ) mmol/L; K (potassium): 5 (3.5–5.0) mmol/L; Cl (chloride): 110 (95–108) mmol/L; BUN (blood urea nitrogen): 5 (7–18) mg/dL; HCO3 (bicarbonate): 28 (22–30) mmol/L; CR (creatinine): 0.79 (0.8–1.2) mg/dL; glucose: 69 (70–99) mg/dL

image  WBC (white blood cell count): 13.3 (4.0–14.0) × 1,000 cells/mm3; hemoglobin: 15 (12.0–16.0) g/dL; hematocrit: 42 (36.0–46.0) %; PLT: 223 (150–400) × 103/mm3

image  Opiate screen: Negative

image  ETOH (alcohol): Nondetected

image  Serum pregnancy: Negative

image  UA (urinalysis): Negative

The results of these laboratory studies and your complete physical exam allow you to rule out dehydration, hypoglycemia, anemia, pregnancy, and drug and alcohol use as the etiology of Emma’s syncopal episode.

At this point, what are the differential diagnoses you should consider in this case? image

Upon review of your differential diagnosis you note the following:

Neurologic: Both seizure and cerebral concussion diagnoses are unlikely due to lack of history or physician findings that indicate trauma, headaches, or seizure activity.

Cardiac: A cardiac problem is an unlikely diagnosis with a normal ECG. You know that syncope that occurs during physical exertion is very concerning for a cardiac etiology, whereas syncope after exertion may occur with vaso-vagal syncope or cardiac conditions (Driscoll et al., 1997).

•  Cardiac arrhythmias including long QT syndrome: Unlikely diagnosis due to a physical examination with normal cardiac sounds and normal ECG without prolonged QT or other cardiac arrhythmias or structural abnormalities and no family history of sudden death.

•  Neurocardiogenic/vasovagal: This is your most likely diagnosis due to a history of syncope after physical exertion associated with change of posture, dizziness, blurred vision, and short recovery. Finally, there is no evidence by history of seizure activity or a prolonged postictal period associated with loss of bowel or bladder control.

Pregnancy: This is not supported by history, physician exam, and/or laboratory testing.

Psychogenic: There is no presyncopal report of hyperventilation or breath holding. There is a remote possibility that an added benign cause of syncope could be due to recent school change, family stressors, and divorce; however, this is not supported by report and family history from Emma, Mrs. Kaplan, or her coach.

•  Hyperventilation or breath holding: Not supported by history.

•  Hysteria (somatization disorder) or a conversion disorder: Not supported by Emma’s report, coach’s report, and mother’s history.

Medications or illicit drugs including antidepressant drugs or toxins: carbon monoxide poisoning, inhalant/huffing: Not supported by history and laboratory testing.

Dehydration/volume depletion: Not supported by physical exam, weight loss, vital signs, and laboratory findings.

What other tests do you need to make your diagnosis and then decide on a plan of care? image

Laboratory Blood Work

In the asymptomatic patient, laboratory blood work is rarely helpful; however, specific laboratory tests may be useful.

•  Bedside blood glucose for children who present immediately after the episode

•  Hematocrit for children who are at risk for anemia

•  Urine pregnancy test in postmenarchal females

•  Urine toxicology screen in patients with altered metal status

Electrocardiogram, Echocardiogram, and Imaging Studies

Cost Effectiveness of Testing

In a study of 480 pediatric patients, an abnormal history, physical examination, or electrocardiogram identified 21 of the 22 patients with a cardiac cause of syncope. Electrocardiography provides a screening protocol that allows the identification of a cardiac cause of syncope in the overwhelming majority of pediatric patients. In the absence of ECG changes, the echocardiogram does not contribute to the evaluation of syncope in children (Ritter et al., 2000).

In a retrospective review of 169 pediatric patients with new onset syncope, the results revealed the cost based on testing for fiscal year 1999. A total of 663 tests were performed at a cost of $180,128. Only 26 tests (3.9%) were diagnostic in 24 patients (14.2%). The average cost per patient was $1,055, and the cost per diagnostic result was $6,928. Echocardiograms, chest radiographs, cardiac catheterizations, electrophysiology studies, and serum evaluations were not diagnostic. Thus, the evaluation of pediatric syncope remains expensive and the above testing has a low diagnostic yield. An approach that focuses on the use of testing to verify findings from the history and physical examination or exclude life-threatening causes is justified (Steinberg & Knilans, 2005).

Given your list of possible diagnoses and the information regarding the value of various tests, you decide that you need to order a 12-lead ECG, which reveals a normal sinus rhythm. In Emma’s case, the results for all of the listed studies conducted on her were normal.

Making the Diagnosis

What is the most likely diagnosis regarding Emma’s syncopal episode? image

You have arrived at your diagnosis of neurocardiogenic syncope/vasovagal-related syncope using an algorithmic approach to the emergent evaluation of syncope in children and adolescents, as outlined in Figure 23-1. This algorithm provides a systematic method to assess the etiology of a syncope episode in a child or adolescent and serves as a practice guide that the healthcare provider can quickly use in either the ED or primary care setting.

image

Figure 23-1  Emergent evaluation of syncope in children and adolescents.


Source:© 2008 UpToDate.

Management

Does Emma need further specialty referrals or admission to the hospital? image

Indications for Referral or Admission

The majority of children, like Emma, who have had syncope with a negative evaluation can be followed as outpatients. Concerning features such as absence of a significant prodrome, palpitations or chest pain, a family history of syncope or sudden death, and recurrent episodes should be referred for further cardiac evaluation. Follow-up consultation with a neurologist should be considered for children with prolonged loss of consciousness and/or a history of focal neurologic findings.

Admission to the hospital for further evaluation and observation should be considered under the following circumstances:

•  Evidence of cardiovascular disease

•  An abnormal ECG

•  Chest pain

•  Cyanosis

•  Apnea or bradycardic spells that resolve only with vigorous stimulation

•  Abnormal neurologic findings

•  Orthostatic hypotension that does not resolve with fluid therapy

Emma’s clinical presentation and subsequent findings meet none of the criteria for admission to the hospital for additional observation or testing.

Best Practice Evidence for Managing Emma’s Syncopal Event

Now that you have thoroughly evaluated Emma’s syncopal event using data obtained from her history, physical examination, and first line diagnostic studies using a systematic approach to data collection, and having come to your diagnosis of neurocardiogenic syncope (vasovagal), you are ready to discuss this event and its likely etiology with Emma and her mother.

Emma’s mother is very upset after all the questions and many tests, which seem to her to indicate that Emma might have a “heart condition.” What will you tell her? image

It is important that Mrs. Kaplan, Emma, and her coach understand that Emma does not have a heart problem. There are no family risk factors such as a family history of early cardiac death (less than 45 years of age), sudden deaths including unexplained accidents involving a single motor vehicle or drowning, known arrhythmia (long QT syndrome), and familial cardiomyopathy. In addition, syncope that occurs during physical exertion is very concerning for a cardiac etiology, whereas syncope after exertion may occur with vasovagal syncope or cardiac conditions (Driscoll et al., 1997). Emma passed out afterphysical activity, which is more consistent with a noncardiac etiology. A normal ECG is one of the most important tests to evaluate syncope. Emma’s ECG is normal, indicating the unlikelihood that Emma has a heart condition.

It is documented that up to 15% of children experience a syncopal episode prior to the end of adolescence (Lewis & Dhala, 1999), and that fainting is a transient loss of consciousness, which typically occurs after activity. Similarly, Emma’s symptoms match patients who have had vasovagal syncope. Prior to the event and her loss of consciousness, Emma changed position, going from the huddle to standing. She reported feeling dizziness, lightheadedness, sweating, nausea, and weakness, and had blurred vision. Her loss of consciousness was short with no postictal state/prolonged unconsciousness, and she did not have seizure activity or loss of bladder or bowel control. These are Emma’s exact symptoms and are due to vasovagal syncope.

Emma wants to know if she can return to sports tomorrow. What will you tell her? image

Emma may return to sports tomorrow. She should take the following precautions:


image  Increase fluids intake and avoid dehydration.

image  Increase salt in diet.

image  Assume sitting/supine position at onset of symptoms.

image  Avoid noxious stimuli (i.e., avoid hot environment or prolonged standing/kneeling).

image  Address anxiety/stress/emotional concerns.

Other potentially helpful management interventions that might be considered in select cases include:

•  Use of physical exercise/training to increase muscular tone. Exercise prompts fitness, which counteracts neurocardiogenic syncope but can make symptoms worse initially. Therefore, it should be done cautiously at first.

•  Use of waist-high support hose to prevent pooling (knee-high hose may not work well).

The coach was also worried about Emma and asked that you send him a note or call him regarding her condition.

What will you tell the coach? image

With the family’s approval, the healthcare provider can tell the coach and also write him a note stating Emma’s ECG findings are normal and that she does not have a cardiac etiology to this fainting spell. By Emma taking the precautions listed previously, she will decrease the possibility of a similar event. However, if Emma and the coach do not follow the precautions, it is remotely possible that she may have another syncopal event.

Suggest that the coach and athletic trainers consider administering the 2004 American Academy of Pediatrics Pre-sports Participation Form as a part of their screening procedure for students applying for school sports.

Key Points from This Case

1. Syncope is a sudden, brief loss of consciousness associated with loss of postural tone from which recovery is spontaneous.

2. Syncope in children is most often benign. However, syncope can also occur as the result of more serious cardiac disease with the potential for sudden death.

3. A complete history and physical examination and ECG findings typically identify children with a life-threatening cause of syncope.

4. A patient with a normal ECG has a low likelihood of arrhythmia as a cause of syncope (Kapoor, 2000).

5. The use of additional testing, beyond history, physical examination, and ECG, can be avoided in many patients with transient loss of consciousness (van Dijk et al., 2008).

6. Syncope that occurs during physical exertion is very concerning for a cardiac etiology, whereas syncope after exertion may occur with vaso-vagal syncope or cardiac conditions (Driscoll et al., 1997).

7. In some studies, echocardiograms, chest radiographs, cardiac catheter-izations, electrophysiology studies, tilt table test, and serum evaluations were found to be neither cost-effective nor diagnostic.

8. The responsibility of the primary care provider is to quickly identify the child or adolescent who needs a referral to the appropriate specialist. For example, when a cardiac etiology is identified, such as a structural heart disease or arrhythmias, a cardiology consult should be made for further evaluation and management. Similarly, when a neurologic etiology is identified, such as a seizure or head trauma, a neurologic consult should be made for further evaluation and management.

9. An algorithmic approach to syncope is recommended.

REFERENCES

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Gillette, P. C., & Garson, A. Jr. (1992). Sudden cardiac death in the pediatric population. Circulation, 85, (1 Suppl): 164–169. Review.

Kapoor, W. N. (2000). Syncope. New England Journal of Medicine, 343, 1856–1862.

Kapoor, W. N., Peterson, J. R., Wieand, H. S., & Karpf, M. (1987). Diagnostic and prognostic implications of recurrences in patients with syncope. American Journal of Medicine, 83, 700–708.

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Ritter, S., Tani, L. Y., Etheridge, S. P., Williams, R. V., Craig, J. E., Minich, L. L. (2000). What is the yield of screening echocardiography in pediatric syncope? Pediatrics, 105, E58.

Steinberg, L. A., & Knilans, T. K. (2005). Syncope in children: diagnostic tests have a high cost and low yield. Journal of Pediatrics, 146(3), 335–338.

van Dijk N., Boer, K. R., Colman, N., Bakker, A., Stam, J., van Grieken, J. J., et al. (2008). High diagnostic yield and accuracy of history, physical examination, and ECG in patients with transient loss of consciousness in FAST: the Fainting Assessment Study. Journal of Cardiovascular Electrophysiology, 19, 48–55.