1. Pediatric Emergency Medicine Core Education Module
2010
CMC Department of Emergency Medicine
Division of Pediatric Emergency Medicine

2. Objectives
At the end of this module you will be able to:
Define syncope
Discuss possible mimics of syncope
Describe an appropriate emergency department evaluation
of syncope
Discuss high risk characteristics of patients with syncopal
episodes

3. What is Syncope?
Brief sudden loss of consciousness with loss of
postural tone that resolves spontaneously
Pre-syncope refers to feeling faint without true loss of
consciousness
Literature reports it occurs in 15-50% of adolescents

4. What Causes Syncope
In children and adolescents, the most common cause is
vasovagal
Our job is to rule out the life threatening causes
Dysrhythmias (usually tachydysrhythmias)
Cardiac outflow obstructions
Toxic exposures
Hypoglycemia
Ectopic pregnancy

5. Beware the Mimics
Seizures
Migraines
Hyperventilation
Choking games
Hysteria/conversion

6. Where to begin your
evaluation?
History! Warning signs!
What was happening around Triggered by fright or sound
the patient? No prodrome
What did he/she feel Exertional
like/sense before the event? Palpitations or chest pain
What position was he/she in
Brief posturing
when it happened?
Family history of sudden
Did he/she have chest pain or
cardiac death, known
headache before/after? arrhythmia
Try to get a witness!
Congenital heart disease

7. Other questions to consider…
More history Family history
Menstrual history Early cardiac death <45y
Medical problems Known arrhythmia
Access to medications or Familial cardiomyopathy
illicit drugs

8. Physical Exam
Orthostatics
Change from sitting to standing
Decrease of SBP >20 or increase of HR> 20
More important than the numbers is ability to recreate
symptoms
Normal does not exclude cardiac dysrhythmia
Complete vitals including 4 extremity BP

9. Physical Exam
Full physical exam with emphasis on:
Detailed neurologic exam
Cardiac exam
 -Murmurs, rubs and gallops
 -Signs of heart failure
Document carefully and thoroughly

10. Testing
Accu-check!
especially if patient is not at mental baseline or event was
recent
ECG
Urine pregnancy test
Hemoglobin
Urine drug screen (if still altered)
No neurologic imaging is indicated unless persistent focal
neurologic abnormality.

11. What Cardiac Diagnoses
Are We Looking For?!?
Plumbing Problems Electrical Problems
Hypertrophic Long QT
cardiomyopathy Brugada
Anomolous coronary arteries Polymorphic VT
Ventricular cardiomyopathy Congenital short QT
Aortic stenosis Pre-excitation (Wolff-
Pulmonary hypertension Parkinson-White syndrome)
Acute myocarditis
Dilated cardiomyopathy

12. Long QT
Mattu, A and Brady, W. ECGs for the Emergency Physician 2. p 30.
• Delayed repolarization
• May be familial (ask about family history)
• QTc = >460ms
• Can cause syncope from ventricular dysrhythmia → Torsades de Pointes →
ventricular fibrillation arrest
• Treatment = beta blockers

13. Brugada Pattern
Mattu, A and Brady, W. ECGs for the Emergency Physician 2. pg 126.
• RBBB or incomplete RBBB pattern in V1-V2 with ST Elevation
• At risk for monomorphic and polymorphic ventricular tachycardia
• Need pacemakers

14. Short QT
• QTc<320
• Increased incidence of atrial fibrillation
• May indicate an electrolyte abnormality (hypercalcemia for example)
• High risk of ventricular dysrhythmia and sudden cardiac death
Mattu, A and Brady, W. ECGs for the Emergency Physician 2. pg 160.

15. Wolff-Parkinson-White Syndrome
Mattu, A and Brady, W. ECGs for the Emergency Physician 2. pg 60.
• Short PR interval and delta wave are diagnostic
• Represent signal transmitting around the AV node through a Bundle of Kent
• Can go into tachydysrhythmias…BEWARE….can be wide complex irregular tachycardia
• If stable may want to discuss with cardiology prior to drug administration
as adenosine and diltiazem can be problematic
• Unstable → SHOCK

16. Who needs cardiology consultation / follow-up?
Family history of sudden death or malignant arrhythmia
Exercise related syncope
Cardiac history
If abnormal ECG, fax to cardiology for an interpretation
prior to admitting patient

17. High Yield Points
If patient is at baseline, there is little need for extensive
work-up
Screening ECG, though low yield, will screen for most life
threatening cardiac syncope
Look for anemia, hypoglycemia
Always check urine pregnancy test
No indication for ED neuro-imaging in a child without
focal neurologic sign

18. Interesting Articles
Goble MM, et al. ED management of pediatric syncope:
searching for a rationale. American Journal of Emergency
Medicine, 2008; 26: 66-70.
Dovyalyuk J, et al. The electrocardiogram in the patient
with syncope. American Journal of Emergency Medicine,
2007; 25(6): 688-701.

19. Please contact Sean M. Fox, MD with any questions or comments.
Carolinas Medical Center
Medical Education Building, 3rd Floor
1000 Blythe Blvd
Charlotte, NC 28270
Office: (704) 355-7205
Email: sean.fox@carolinashealthcare.org