We review a general approach to syncope in children.
Hosts:
Brian Gilberti, MD
Ellen Duncan, MD
Episode 192: Syncope in Children
Show Notes
- Initial Evaluation and Management:
- Similar initial workup for children and adults: checking glucose levels for hypoglycemia and conducting an EKG.
- The history and physical exam are crucial.
- Dextrose Administration in Children:
- Explanation of the ‘rule of 50s’ for determining the appropriate dextrose solution and dosage for children.
- ECG Analysis:
- Importance of ECG in diagnosing dysrhythmias like long QT syndrome, Brugada syndrome, catecholamine polymorphic V tach, ARVD, ALCAPA, and Wolff-Parkinson-White syndrome.
- Younger children’s dependency on heart rate for cardiac output and the risk of arrhythmias in kids with congenital heart disease.
| Condition | Characteristic ECG Findings | Congenital/Acquired |
|---|---|---|
| Long QT Syndrome (LQTS) | Prolonged QT interval | Congenital/Acquired |
| Wolff-Parkinson-White Syndrome (WPW) | Short PR interval, Delta wave | Congenital |
| Brugada Syndrome | ST elevation in V1-V3, Right bundle branch block | Congenital |
| Atrioventricular Block (AV Block) | PR interval prolongation (1st degree), Missing QRS complexes (2nd & 3rd degree) | Congenital/Acquired |
| Supraventricular Tachycardia (SVT) | Narrow QRS complexes, Absence of P waves, Tachycardia | Congenital/Acquired |
| Ventricular Tachycardia | Wide QRS complexes, Tachycardia | Congenital/Acquired |
| Arrhythmogenic Right Ventricular Dysplasia (ARVD/C) | Epsilon waves, V1-V3 T wave inversions, Right bundle branch block | Congenital |
| Hypertrophic Cardiomyopathy (HCM) | Left ventricular hypertrophy, Deep Q waves | Congenital |
| Pulmonary Hypertension | Right ventricular hypertrophy, Right axis deviation | Acquired |
| Athlete’s Heart | Sinus bradycardia, Voltage criteria for left ventricular hypertrophy | Acquired |
| Catecholaminergic Polymorphic VT (CPVT) | Bidirectional or polymorphic VT, typically normal at rest | Congenital |
| Anomalous Origin of Left Coronary Artery from Pulmonary Artery (ALCAPA) | May be normal, signs of ischemia or infarction in severe cases | Congenital |
- History Taking:
- Key aspects include asking about syncope with exertion, syncope after being startled, and syncope after pain or emotional stress.
- Prolonged loss of consciousness may indicate seizures, and emotional stress and pain can trigger breath-holding spells.
- Breath-Holding Spells:
- Clarification of misconceptions about breath-holding spells, discussing their causes and characteristics, like cyanotic and pallid types.
- Association with iron deficiency and the fact that most children outgrow these spells by age 8.
- Physical Examination and History:
- A cardiac exam is vital, with specific signs to look for, like murmurs in hypertrophic cardiomyopathy.
- History can help identify the etiology of syncope, such as vasovagal responses or orthostatic hypotension.
- Vasovagal Syncope:
- Common in kids, especially teenagers, typically presenting with a prodrome of lightheadedness, diaphoresis, and pallor.
- Normal glucose and EKG are expected in these cases.
- Additional Lab Tests:
- Pregnancy tests in reproductive-age women, and checking for less common causes like pulmonary embolism, subarachnoid hemorrhage, and toxic exposures.
Take Home Points:
- Immediate assessments for syncope in children should include a FS to evaluate for hypoglycemia and an ECG to evaluate any cardiac rhythm or conduction abnormalities.
- Apply the “Rule of 50s” for hypoglycemic patients to suggest which fluids should be used.
- Refer to our table for ECG findings to look out for when reviewing ECG tracings for these patients.
- Pay particular attention to clues in the history that would suggested HCOM or seizures.
- Breath-holding spells usually resolve by eight
- HCOM murmurs will increase with Valsalva maneuverÂ
- Always keep your differential broad when approaching these patients given the heterogeneity of potential pathology that could lead to this chief complaint
