Episode 192: Syncope in Children

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Jan 3, 2024

The podcast discusses the approach to syncope in children, including initial workup similarities for children and adults, the rule of 50s for dextrose administration, and the importance of ECG analysis for diagnosing dysrhythmias. Topics covered include long QT syndrome, Brugada syndrome, and Wolff-Parkinson-White syndrome, emphasizing the need for a comprehensive evaluation and management in pediatric syncope cases.

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ADVICE

Initial Rapid Tests

Check a point-of-care glucose and obtain an ECG immediately for any child with syncope.
Use history and physical exam to guide further testing rather than reflexive labs.

ADVICE

Rule Of 50s For Dextrose

Apply the 'rule of 50s' to pick dextrose concentration and volume for hypoglycemic children.
Multiply percent dextrose by mL/kg to equal 50 (e.g., 10% × 5 mL/kg = 50).

INSIGHT

ECG Reveals Critical Pediatric Causes

Pediatric ECGs can reveal life-threatening inherited or structural causes of syncope.
Younger children rely on heart rate for cardiac output, so bradycardia or AV block can cause syncope.

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We review a general approach to syncope in children.

Hosts:
Brian Gilberti, MD
Ellen Duncan, MD

Download Leave a Comment Tags: Cardiology, Pediatrics

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.

Condition	Characteristic ECG Findings	Congenital/Acquired
Long QT Syndrome (LQTS)	Prolonged QT interval	Congenital/Acquired
Wolff-Parkinson-White Syndrome (WPW)	Short PR interval, Delta wave	Congenital
Brugada Syndrome	ST elevation in V1-V3, Right bundle branch block	Congenital
Atrioventricular Block (AV Block)	PR interval prolongation (1st degree), Missing QRS complexes (2nd & 3rd degree)	Congenital/Acquired
Supraventricular Tachycardia (SVT)	Narrow QRS complexes, Absence of P waves, Tachycardia	Congenital/Acquired
Ventricular Tachycardia	Wide QRS complexes, Tachycardia	Congenital/Acquired
Arrhythmogenic Right Ventricular Dysplasia (ARVD/C)	Epsilon waves, V1-V3 T wave inversions, Right bundle branch block	Congenital
Hypertrophic Cardiomyopathy (HCM)	Left ventricular hypertrophy, Deep Q waves	Congenital
Pulmonary Hypertension	Right ventricular hypertrophy, Right axis deviation	Acquired
Athlete’s Heart	Sinus bradycardia, Voltage criteria for left ventricular hypertrophy	Acquired
Catecholaminergic Polymorphic VT (CPVT)	Bidirectional or polymorphic VT, typically normal at rest	Congenital
Anomalous Origin of Left Coronary Artery from Pulmonary Artery (ALCAPA)	May be normal, signs of ischemia or infarction in severe cases	Congenital

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