Pediatric emergency medicine trisk 1518 1518
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stress testing may be helpful in the diagnosis of channelopathies, such as LQTS
and CPVT, which have adrenergically mediated arrhythmias.
The head-upright tilt table test (HUTT) may be used to provoke a hypotensive
episode that mimics the patient’s symptoms. However, it has low sensitivity, and
current guidelines recommend it only in cases when the diagnosis of vasovagal
syncope is truly unclear. Pediatric patients with episodes of vasovagal syncope
may exhibit convulsive movements during loss of consciousness that mimic
epileptic seizures; HUTT may help in differentiating children with a primary
seizure disorder. A combined cardiology and neurology evaluation may be
warranted in patients with syncope and seizure-like activity. Additional
indications for use of HUTT are recurrent syncope or exertional syncope in which
heart disease has been ruled out, or recurrent syncopal episodes thought to be due
to conversion disorder.
Neurologic Testing
Neuroimaging is rarely required for a typical patient with syncope and the
diagnostic yield is likely to be low. The only indication for neuroimaging is for a
patient with focal neurologic deficits or persistently altered mental status in
whom it is necessary to rule out significant intracranial injury or cerebrovascular
accident. An electroencephalogram (EEG) may be performed on an outpatient
basis if clinical features suggest a seizure and the patient has returned to a
baseline neurologic status. However, it is important to remember that a normal
EEG does not rule out epilepsy.
TREATMENT
Most children with syncope can be managed on an outpatient basis. Patients with
vasovagal syncope and their families will need reassurance and education about
the benign nature of the condition. They should be taught how to recognize
prodromal symptoms and avoid precipitating factors such as dehydration,
standing for prolonged periods, hot crowded environments, and diuretic intake.
Maneuvers to prevent venous pooling (such as keeping the knees slightly bent
when standing for a long time, isometric contraction of extremity muscles, toe
raises, folding of the arms, and crossing of the legs) or even assuming a seated or
supine position may help. Patients should be encouraged to increase their oral
intake of water (up to 3 L per day in an adolescent), to add salty snacks to their
diet, and to avoid consuming caffeinated beverages. If increased fluid and salt
intake are not helpful, pharmacotherapy may be considered in patients with
recurrent syncope.
