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Children may present to the emergency department with a potential syncopal event. Although the presentation is unusual, everyone fears missing a cardiac issue. The authors present a concise review, focusing on the history, physical exam, and ECG, of how to evaluate and manage a child with syncope, differentiating other mimics and discussing the current therapeutic approach to the most common diagnosis.
— Ann M. Dietrich, MD, FAAP, FACEP
Definition of the Problem
Syncope is defined as a rapid-onset, transient loss of consciousness, with complete spontaneous recovery to the patient’s baseline mental status due to transient cerebral hypoperfusion.1 Syncope and pre-syncope in the pediatric patient are common presenting problems for the emergency provider (EP). Most presentations are benign, and only approximately 2% of patients will have a serious underlying cardiac cause of the event.2,3 The challenge for the EP is to identify these rare life-threatening presentations, differentiating syncope from other potential serious disorders, all while balancing appropriate testing to avoid unnecessary interventions. This article will address the epidemiology of syncope in pediatric patients, the causes and classification of syncope, as well as disorders that mimic it, and provide an algorithm for the evaluation, management, and disposition of pediatric patients who present with syncope to the emergency department (ED). It will not address other causes of transient loss of consciousness, such as head injuries, cerebrovascular accidents, or toxic ingestions.
Epidemiology
Syncope is a common presenting problem in the pediatric population, representing slightly less than 1% of all pediatric ED presentations. Approximately 40% of girls and 20% of boys experience a syncopal event by the age of 18 years.2-5 The incidence increases with age and peaks in adolescence, with girls presenting more often than boys.2,3,6 The underlying pathophysiology processes leading to syncope are similar in both adult and pediatric patients, but the incidence of more serious cardiac arrhythmias and structural abnormalities is higher in adult patients.7 Of undifferentiated pediatric patients presenting to the ED with complaints of syncope or pre-syncope, the majority will have neurally mediated (predominantly vasovagal) and orthostatic syncope, approximately 9% will have neurological disorders including seizures, and approximately 2% will have an underlying cardiac cause.2-3 Of patients with an underlying cardiac cause, excluding patients with a known preexisting...