Syncope in children

Syncope (fainting) is a brief loss of consciousness and loss of postural tone with spontaneous recovery.  

Most cases are benign- vasovagal or hypotension related

Hence, your main task is to differentiate a simple faint from other causes primarily with a good history, examination and ECG 

 

Simple causes

1.Vasovagal: prodrome of nausea & sweating; triggered by pain, anxiety, prolonged standing or a warm place

2.Orthostatic: triggered by dehydration, alcohol & BP medications

3.Situational: micturition, cough, defecation; or by carotid sinus pressure

 

Worrying causes

1.Cardiac Structural problems: Hypertrophic cardiomyopathy, Aortic Stenosis, etc

2.Cardiac rhythm abnormalities: VT, WPW syndrome, Congenital long QTc syndrome, Heart block, etc

 

History:

– Sequence of events (before, during & after episode)

– Describe posture, duration of LOC

– Any stiffness / jerking?

– Contributory factors?

– Associated palpitations, chest pain or breathlessness?

– PMH

– Medications (hypotensive)

– Family h/o cardiac issues

 

Examination:

– Pulse rate, rhythm

– Blood pressure, lying & standing

– Hydration status

– Focussed Cardiac and Neurological exam

– Check BM & ECG

 

Red Flags in syncope:

– With exercise

– With palpitations or chest pain

– No warning or prodrome

– Known cardiac problem

– F/H/O arrhythmia or early death

Key ECG changes to look for:

PR interval

short PR and delta wave?… WPW syndrome

long PR?… type II or type-III heart block

 

QTc interval prolonged?

Congenital prolonged QTc syndromes

Any recent medication prolonging QTc?

 

QRS complexes 

increased tall R on V1 or deep S on V5, V6…. is there RV hypertrophy?… HOCM

Tachy with wide QRS/ ventricular pre-excitation/ ectopics?……. VT, BBB

 

ST / T wave changes … acute myocarditis

 

Management of simple faints:

– Explanation about nature of episodes & reassurance

– Identifying / avoiding precipitants

– Self-management of symptoms- patients should sit or lie down if recognising early warnings of fainting; will also prevent injuries

– Maintain good hydration, avoid skipping meals & adequate salt in diet

 

What specialist tests may be considered?

– Holter ECG (24-hour tape)

– ECHO

– Exercise ECG testing / stress test

– Tilt-table testing