Pediatric syncope/presyncope (8 - 18 years)

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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

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