Syncope
Syncope: Excerpt from Pediatric Complaints and Diagnostic Dilemmas
Phillip Spandorfer
Approach to the Patient with Syncope
I. Definition of the Complaint
Syncope is generally thought of as a temporary, but sudden, loss of
consciousness and postural tone. It is caused by a reversible interruption of
cerebral function, typically due to a deficit of cerebral oxygen or glucose
delivery. The deficit in oxygen delivery may be caused by decreased cardiac
output, peripheral vasodilatation, or obstruction of cerebral blood flow. It is
important to differentiate the episode of syncope from other etiologies that
appear like syncope, such as seizure and near-syncopal episodes. Painful
events, episodes of micturition or defecation, and stress frequently precede
syncope. Sweating and nausea before the episode are common as well. Seizures
frequently have no prodromal period, but they may be associated with an aura
before the event. Seizures are frequently associated with tonic-clonic
movements during the event; however, syncopal events that last 20 seconds or
longer can also be associated with very brief tonic-clonic movements. Confusion
after the event, prolonged return to normal state of consciousness, and
unconsciousness lasting longer than 5 minutes suggest seizure activity. During
near-syncopal episodes, patients feel as if they are about to lose
consciousness but do not actually become unconscious.
Syncope is a common complaint in pediatrics. Approximately 15% of children have
a syncopal episode by the time they reach adulthood.
II. Complaint by Cause and Frequency
Pediatric causes of syncope are generally benign, but syncope may signal
serious, life-threatening causes, particularly if it is recurrent or there is a
family history of sudden cardiac arrest. In children, common causes of syncope
include vasovagal episodes, orthostatic hypotension, and breath-holding spells
(Table 18-1). In contrast, most adult syncope has a cardiac origin. The goal in
evaluating syncope is to differentiate benign causes from more worrisome
etiologies (Table 18-2).
III. Clarifying Questions
• Were there any palpitations or unusual heartbeats?
— If the child reports palpitations, then a cardiac dysrhythmia should be
considered.
• Did the syncope occur with activity?
— Syncope that occurs with activity is particularly concerning for idiopathic
hypertrophic cardiomyopathy (HCM).
• Was there a prodrome?
— Migraines and some seizure types may cause symptoms before the actual episode.
• Did the syncope happen on standing?
— Orthostatic hypotension is associated with syncope on standing.
• Was there pain, fear, or some disturbing visual sight before the syncope?
— Strong emotional impulses may stimulate a vasovagal response and ultimately
syncope.
• Was there any seizure-like activity?
— Brief seizure-like motor activity can occur with vasovagal syncope. Prolonged
seizure activity should prompt a more thorough seizure workup. There is no
significant postictal period with the seizure-like activity associated with
syncope.
• How long did it take to return to baseline?
— Vasovagal syncope is associated with a relatively quick (minutes) return to
baseline mental status as soon as cerebral blood flow is restored. If there is
a delay in assuming a recumbent position, there may be a longer delay in return
to baseline mental status.
• Is there a history of trauma?
— A recent history of head trauma raises concern for intracranial hemorrhage.
• Is there a history of anemia?
— Anemic patients may be more likely to have a syncopal episode because of
decreased cerebral oxygen delivery.
Pictures
Book Source Details
- Book Title: Pediatric Complaints and Diagnostic Dilemmas
- Author(s): Samir S Shah MD; Stephen Ludwig MD
- Year of Publication: 2003
- Copyright Details: Pediatric Complaints and Diagnostic Dilemmas, Copyright © 2003 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
» Next page: Remember to think broadly about the differential diagnosis of syncope in children (Avoiding Common Pediatric Errors)
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