Pediatric emergency medicine trisk 1514 1514
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also be seen in vasovagal syncope. Chest pain preceding syncope is almost never
present in patients with primary electrical disorders of the heart but is more likely
in patients with cardiomyopathies, congenital coronary artery abnormalities, or
aortic disease (e.g., dissection or rupture associated with Marfan syndrome). With
seizures, there may be posturing, clonic contractions or incontinence followed by
postictal confusion, and the total time of the event is likely to be longer than that
in a true syncope. Rarely, syncope may be severe enough to result in
cardiopulmonary resuscitation, and any interventions by bystanders or emergency
medical services should be discussed. Children and especially young athletes who
have been outdoors for prolonged periods in warm weather may be at risk for
dehydration and heat syncope.
The past medical history may also provide information about the etiology for
syncope. Families may give a history of congenital heart disease, cardiac surgery
or acquired conditions such as Kawasaki disease, rheumatic heart disease,
myocarditis, or arrhythmia. Patients with seizure disorders, anemia, diabetes, or
psychiatric conditions may also present with syncopal events. It is important to
ask pubescent and adolescent girls about their menstrual history and the date of
the last menstrual period, since pregnancy or dysfunctional uterine bleeding with
resulting anemia may cause syncope. Adolescent patients with eating disorders
may also present with syncope. Use of therapeutic or recreational drugs that cause
dehydration, heart rhythm disturbances, hypotension or mental status changes
may be associated with syncope.
When inquiring about the family history, ask if there was a sudden death of any
family member less than 50 years of age, any unexplained deaths, sudden infant
death syndrome (SIDS), drowning, or motor vehicle crashes. Such events may
occur in patients with LQTS or Brugada syndrome. Also ask for any family
history of enlarged heart or heart rhythm problems, heart attack at age 50 or
younger, pacemaker or implanted defibrillator, deafness at birth,
hypercholesterolemia, Marfan syndrome, or unexplained fainting or seizures. A
family history of vasovagal syncope may be present; genetic factors have been
found to play a role in this disorder, though most cases follow complex patterns
of inheritance and autosomal dominant inheritance is rarely seen.
In most children with syncope, the physical examination is normal. The
physical examination should focus on the vital signs, and the cardiac and
neurologic examinations. Calculate the body mass index (BMI) in patients
suspected to have an eating disorder and inspect the patient for a Marfanoid body
habitus. Check the patient for orthostatic changes as follows. Place the patient in
the supine position for 2 minutes and then measure the BP and heart rate. Count
