LOC associated with episode of abnormal breathing?
Associated with prodrome: dizziness, lightheadedness, nausea, sweating, weakness, changes in vision, fading of noises?
Concerning for hypoglycemia: known endocrinologic condition (e.g., diabetes)?
Requires hospital admission?
Counsel and treat as necessary.
Complete a full history and physical exam, including:
- Vital signs
- Cardiac exam: assessing for murmurs, changes in intensity of murmurs with positional changes, sign of heart failure (e.g., hepatomegaly, edema, gallop)
- Neuro exam: focal deficits, mental status
Concerning for anemia: heavy menstrual cycle, blood loss, history of anemia?
Cardiac Red Flags:
- Syncope with exertion, chest pain, palpitations, while swimming, or with loud noise or stimulae.
- History of congenital heart disease.
- Abnormal cardiac exam:
- Systolic ejection murmur and ejection click → aortic stenosis
- Murmur with increased intensity from squatting to standing or decreased intensity from standing to squatting or with Valsalva → hypertrophic cardiomyopathy
- Other non-innocent murmurs
- Murmurs 3/6 or louder
- Signs of heart failure (e.g., hepatomegaly, edema, gallop)
- Abnormal ECG:
- Prolonged or short QT interval
- Delta waves suggestive of Wolff-Parkinson-White
- Excessive bradycardia or AV block
- Signs of left or right ventricular hypertrophy
- S-T wave changes concerning for pericarditis or ischemia
- Brugada syndrome (pseudo-RBBB with persistent ST segment elevation in leads V1 to V3)
Concern for substance use or abuse?
Work up and treat hypoglycemia.
Check glucose and consider neuroimaging.
- Obtain ECG on all patients.
- Obtain urine pregnancy test on all postmenarchal females.
Consult Cardiology for further work up and management.
If recurrent episodes of syncope with strong personal or family history of migraines, can refer to Neurology for possible pharmacologic intervention.
Work up and treat anemia.
Concerning for migraine: headache, dizziness while seated, flashing lights, family history of migraine?
Provide appropriate counseling and referral to Obstetrics.
Focal neurologic symptoms, altered mental status, or significant head injury?
Concerning for seizure: prolonged loss of consciousness, post-ictal state, incontinence?
Breath-holding spells are benign. Reassurance and education should be provided to the family.
- In a stable pediatric patient without Cardiac or Neurologic Red Flags, the most likely etiology is neurally mediated syncope.
- Treatment includes:
- Reassurance and education regarding trigger avoidance.
- When prodrome is sensed, patient should sit or lay down for 10 minutes.
- Hydration (2L of water per day for adolescents) and regular meals.
- Avoid a low-salt diet.
- Avoid caffeine.
- Follow up with Pediatrician as needed for new or changing symptoms.
- Diagnosis most consistent with neurally mediated syncope.
- Treatment:
- Reassurance and education regarding trigger avoidance.
- When prodrome is sensed, patient should sit or lay down for 10 minutes.
- Hydration (2L of water per day for adolescents) and regular meals.
- Avoid a low-salt diet.
- Avoid caffeine.
- Follow up with Pediatrician as needed for new or changing symptoms.
Key historical questions:
- Duration of loss of consciousness.
- Surrounding events:
- While exercising or at rest
- Acute startle or loud noise
- With change in position (e.g., sitting to standing suddenly)
- Emotional or painful stimulae
- Prolonged period of standing
- Urination, defacation, swallowing, coughing, weight-lifting
- Prodrome:
- Dizziness or lightheadedness
- Changes in vision
- Fading of noises
- Sweating
- Nausea
- Associated symptoms:
- Chest pain
- Palpitations
- Incontinence
- Convulsive-like activity
- Headache
- Recovery time.
- Associated head trauma or injuries.
- Current medications.
- Past medical history:
- Prior syncopal events
- Cardiac conditions such as congenital heart disease, rheumatic heart disease, Kawasaki disease
- Endocrinologic conditions that can cause hypoglycemia such as diabetes mellitus
- Known seizure disorder
- Reasons for anemia such as heavy menstrual bleeding or previously identified anemia
- Substance use or abuse
- Pregnancy
- Family history:
- Sudden cardiac death
- Frequent fainting
- Arrhythmias
- Congenital heard disease
- Cardiomyopathy
- Sudden or unexplained death at <50 years of age
- Heart failure at <50 years of age
- Episode of syncope, fainting, or transient loss of consciousness
- Episode of presyncope or near-fainting
- Clinically unstable
- Major trauma proceeding syncopal event
- Known underlying cardiac or neurologic condition that can result in loss of consciousness
- Known ingestion
Reasons for hospital admission:
- Signs of heart failure.
- Unstable arryhthmia.
- Persistent abnormal neurologic findings
- Orthostatic hypotension with continued syncope despite fluid resuscitation.
Work up and treat accordingly.
