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Pediatric Emergency Medicine Core Education Module
CMC Department of Emergency Medicine
Division of Pediatric Emergency Medicine
At the end of this module you will be able to:
Discuss possible mimics of syncope
Describe an appropriate emergency department evaluation
Discuss high risk characteristics of patients with syncopal
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
Literature reports it occurs in 15-50% of adolescents
What Causes Syncope
In children and adolescents, the most common cause is
Our job is to rule out the life threatening causes
Dysrhythmias (usually tachydysrhythmias)
Cardiac outflow obstructions
Beware the Mimics
Where to begin your
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
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
Other questions to consider…
More history Family history
Menstrual history Early cardiac death <45y
Medical problems Known arrhythmia
Access to medications or Familial cardiomyopathy
Change from sitting to standing
Decrease of SBP >20 or increase of HR> 20
More important than the numbers is ability to recreate
Normal does not exclude cardiac dysrhythmia
Complete vitals including 4 extremity BP
Full physical exam with emphasis on:
Detailed neurologic exam
-Murmurs, rubs and gallops
-Signs of heart failure
Document carefully and thoroughly
especially if patient is not at mental baseline or event was
Urine pregnancy test
Urine drug screen (if still altered)
No neurologic imaging is indicated unless persistent focal
What Cardiac Diagnoses
Are We Looking For?!?
Plumbing Problems Electrical Problems
Hypertrophic Long QT
Anomolous coronary arteries Polymorphic VT
Ventricular cardiomyopathy Congenital short QT
Aortic stenosis Pre-excitation (Wolff-
Pulmonary hypertension Parkinson-White syndrome)
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
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
• 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.
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
Who needs cardiology consultation / follow-up?
Family history of sudden death or malignant arrhythmia
Exercise related syncope
If abnormal ECG, fax to cardiology for an interpretation
prior to admitting patient
High Yield Points
If patient is at baseline, there is little need for extensive
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
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.
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