#pedicatrics

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