I have mixed feelings when I see a patient with syncope in the ED. Most of the time, the diagnosis is reassuring. But every syncopal child carries the same question: is this the first sign of a potentially life-threatening condition? Finding that needle in the haystack is the true challenge.
A teenager faints at school. Another passes out during a choir concert. A third briefly loses consciousness after standing up too quickly. When these children come to your ER, what workup will you do? How will you determine which one of them needs immediate intervention, and which can go home with reassurance?
Some fast facts:
- About 15% of all children experience at least one episode of syncope in their first two decades
- The most common etiology for syncope is vasovagal
- Cardiac causes for syncope occur about 4% of the time
Here are “The 3” Pediatric Syncope Pearls to help you out during your next shift.
1. The Story is More Important Than the Workup
When evaluating a child with syncope, the history is often more valuable than any laboratory test.
Most children with vasovagal syncope describe a recognizable prodrome:
- Lightheadedness
- Dizziness
- Nausea
- Visual changes
- Feeling warm
- Diaphoresis
Often in vasovagal (also known as neurally mediated) syncope, there is a preceding event, such as an extended period in an upright position (Hello, choir concert), dehydration, a vagal trigger, or an external stimulus such as pain or emotional upset (Who hates getting blood drawn?).
Contrast this with the red flag symptoms that should raise concern for a concerning etiology:
- Exertional syncope
- Sudden/No prodromal symptoms
- Preceding or concurrent chest pain or palpitations
- Young child without a suspected breath holding spell
- Headache before syncope
- Prolonged recovery following syncope
Additionally, any concerning family history should raise your suspicion. I tend to ask “Are there any young people in the family who have had sudden, early, or unexplained death?”
HipPEMcrates Pearl: The diagnosis is often made before you touch the computer. Listen carefully to the story.
2. The ECG is the Highest-Yield Test
Every patient coming in with syncope should have an ECG done – it’s non-invasive, a quick test, and can literally save your patient’s life.
While routine lab studies rarely identify the cause of syncope in an otherwise healthy child, and most ECG’s will be normal in patients with syncope, life-threatening conditions can be revealed by this simple test.
Red Flag Findings:
- Prolonged QT Interval (Long QT Syndrome)
- Delta wave (Wolff-Parkinson-White Syndrome)
- ST-segment elevation (if in V1-V3 pattern, concern for Brugada Syndrome)
- Any evidence of ventricular hypertrophy or strain (Cardiomyopathy)
- Pathologic Q waves (Cardiomyopathy or MI)
- 2nd or 3rd degree AV block
HipPEMcrates Pearl: Most of the ECG’s you order will be normal. The more you look at, the better you will be at identifying those that are abnormal.
3. Most Kids Need Reassurance, Not Admission
The vast majority of pediatric syncope is from benign causes.
Children with:
- A reassuring history
- A normal physical exam
- A normal ECG
- Quick return to neurologic baseline
can typically be discharged with education and outpatient follow-up.
Guidance for vasovagal syncope should include:
- Adequate fluid intake (some say about 100 ounces per day for adolescents)
- Adequate salt intake
- Regular exercise
- Avoid skipping meals (Anyone have teenagers?)
- Recognizing higher-risk actions (i.e. standing up from sitting, getting out of bed) and taking those actions slower
For those children with concerning histories, physical exam findings, or an abnormal ECG, consider early involvement from your Cardiology and/or Neurology colleagues, with disposition decided after consultation.
HipPEMcrates Pearl: Most fainting children need fluids, education, and reassurance.
Additional Syncope Resources:
Review Article: Anderson JB, Willis M, Lancaster H, Leonard K, Thomas C. The Evaluation and Management of Pediatric Syncope. Pediatr Neurol. 2016 Feb;55:6-13.
Systematic Review: Zavala R, Metais B, Tuckfield L, DelVecchio M, Aronoff S. Pediatric Syncope: A Systematic Review. Pediatr Emerg Care. 2020 Sep;36(9):442-445.
Podcast: Core EM, Syncope in Children
Blog: Don’t Forget The Bubbles, Syncope in Children
Blog: PEM Blog, Facts on the Ground: Do all pediatric syncope patients need an EKG?
Blog: PEM Blog, A review of the utility of the ECG in Pediatric Syncope
Blog: Pediatric EM Morsels, Brugada in Children
Dr. Joshua Belfer, MD, is a Pediatric Emergency Medicine physician at the Children’s Hospital of Philadelphia, and is the Founder and Editor-in-Chief of HipPEMcrates. He can be reached at HipPEMcrates@gmail.com.
