Pediatric syncope/presyncope (8 - 18 years)
Formal orthostatics are not routinely recommended for syncope/presyncope
Meets discharge criteria?
Pallor or abnormal vital signs?
High risk cardiac factors?
Secondary cardiac risk factors?
Cardiology consult
Inclusion Criteria
- Transient loss of consciousness with loss of tone and spontaneous recovery
- Near fainting episode without loss of consciousness
Exclusion Criteria
- Possible or known ingestion
- Trauma prior to syncope/presyncope
- History of neurologic disease or other severe chronic disease
- Ill-appearing
- History of cardiac disease or cardiac surgery
Complete Blood Count, Serum
Consider pediatric cardiology or neurology consult
Common disease states that can mimic syncope/presyncope
- Severe anemia
- Severe dehydration
- Intoxication
- Metabolic disturbances
- Migraines
- Pulmonary embolism
- Psychogenic events
- Breath holding spell
- Discharge home with PCP follow up
- Potential outpatient lab testing of electrolytes, CBC or thyroid function tests
- Counseling regarding increase fluid intake and consume regular meals
- Recognition and avoidance of triggers
- Isometric muscle contractions and positional changes during the onset of symptoms
Outpatient cardiology referral within 2 weeks
High risk neurologic findings?
Secondary cardiac risk factors
- Borderline ECG
- Family history
- SIDS
- Long QT syndrome
- Hypertrophic cardiomyopathy
- Congenital deafness
- Sudden cardiac death (< 40 years)
- Sudden unexplained death (< 40 years)
Off pathway, consult appropriate specialty service.
Neurology consult, consider neuroimaging
High risk cardiac risk factors
- Syncope with chest pain, exertion, loud noise/arousal, palpitations or while swimming
- Increasing frequency of events
- 3/6 or other non-innocent murmur
- Frequent PAC/PVC on cardiac monitor
- Abnormal ECG
- Wolff-Parkinson White
- LVH (S > 25 mm in V1 or R > 30 mm in V6 or Q > 5 mm in V6)
- RVH (S > 5 mm in V6 or R> 10 mm in V1 or Axis > 130)
- 2nd or 3rd degree heart block
- Bundle branch block with QRS duration > 120 ms
- Abnormal PR interval, axis or QTC
- ST-T pattern concerning for pericarditis or ischemia
High risk neurolgic findings
- Severe headache
- Focal neuro findings
- Signs of epileptic event
- Shaking/jerking motions lasting longer than 15 seconds
- Prolonged period of confusion/post-ictal state
- Loss of bowel or bladder function
- Tongue biting
Place on cardiac monitor (minimum 30 min), detailed history and physicial
Urine Pregnancy, Urine
Glucose by Meter, POC
ECG
