Importance of History-taking and Differential Diagnosis in Pediatric Syncope

Show Notes

• Initial Evaluation and Management:
  • Similar initial workup for children and adults: checking glucose levels for hypoglycemia and conducting an EKG.
  • The history and physical exam are crucial.
• Dextrose Administration in Children:
  • Explanation of the ‘rule of 50s’ for determining the appropriate dextrose solution and dosage for children.
• ECG Analysis:
  • Importance of ECG in diagnosing dysrhythmias like long QT syndrome, Brugada syndrome, catecholamine polymorphic V tach, ARVD, ALCAPA, and Wolff-Parkinson-White syndrome.
  • Younger children’s dependency on heart rate for cardiac output and the risk of arrhythmias in kids with congenital heart disease.

• History Taking:
  • Key aspects include asking about syncope with exertion, syncope after being startled, and syncope after pain or emotional stress.
  • Prolonged loss of consciousness may indicate seizures, and emotional stress and pain can trigger breath-holding spells.
• Breath-Holding Spells:
  • Clarification of misconceptions about breath-holding spells, discussing their causes and characteristics, like cyanotic and pallid types.
  • Association with iron deficiency and the fact that most children outgrow these spells by age 8.
• Physical Examination and History:
  • A cardiac exam is vital, with specific signs to look for, like murmurs in hypertrophic cardiomyopathy.
  • History can help identify the etiology of syncope, such as vasovagal responses or orthostatic hypotension.
• Vasovagal Syncope:
  • Common in kids, especially teenagers, typically presenting with a prodrome of lightheadedness, diaphoresis, and pallor.
  • Normal glucose and EKG are expected in these cases.
• Additional Lab Tests:
  • Pregnancy tests in reproductive-age women, and checking for less common causes like pulmonary embolism, subarachnoid hemorrhage, and toxic exposures.

Take Home Points:

• Immediate assessments for syncope in children should include a FS to evaluate for hypoglycemia and an ECG to evaluate any cardiac rhythm or conduction abnormalities.
• Apply the “Rule of 50s” for hypoglycemic patients to suggest which fluids should be used.
• Refer to our table for ECG findings to look out for when reviewing ECG tracings for these patients.
• Pay particular attention to clues in the history that would suggested HCOM or seizures.
• Breath-holding spells usually resolve by eight
• HCOM murmurs will increase with Valsalva maneuver 
• Always keep your differential broad when approaching these patients given the heterogeneity of potential pathology that could lead to this chief complaint