SYNCOPE

Question 1

History & Physical

Answer 1

Ask about:

Prodromal Symptoms:
-nausea, warmth or light-headedness, gradual visual greyout
-abrupt LOC, chest pain, palpitations, shortness of breath, EXERTION
Duration of LOC
Tonic Clonic Movement
Post Ictal State
Hydration Status
Last Meal
Environmental Conditions
Drug use
Recent illnesses

Ask about:
Personal or family history of cardiac disease or sudden death
Medications

Question 2

Etiology

Answer 2

Neurocardiogenic (80%):
Vasovagal
Orthostatic Hypotension
Situational:
-cough
-micturition
-defecation
-swallow
-neuralgia
Carotid Sinus Syndrome

CARDIAC:
-prolonged QT
-Outflow Obstruction (Hypertrophic Cardiomyopathy)
-Tachydysrhythmias / WPW
-Bradydysrhythmias / AV block
-Myocardia dysfunction

BREATH HOLDING SPELLS (6-18 mo)

Question 3

Risk factors for serious cause of Syncope

Answer 3

Exertion preceding the event

Age < 6

History of cardiac or heart murmur

Family History of sudden death, long QT Syndrome,
sensorineural hearing loss or cardiac disease

Recurrent episodes

Recumbent episode

Prolonged loss of consciousness

Associated chest pain or palpitations

Abscence of premonitory symptoms or physical precipitating factors

Use of medications that can alter cardiac function

Question 4

Physical Exam

Answer 4

Cardiovascular
Neurologic
Pulmonary

Question 5

Investigations

Answer 5

Routine Laboratory studies are not required in a child with a clear episode of vasovagal
syncope

ECG if palpitations or exertional syncope

ECG, CXR, Echocardiography if sudden collapse, murmur on exam

Troponin if chest pain

Question 6

DDX: ECG 2 basic things and 6 exotic things

Answer 6

Basic Things:
Arrythmia
Ischemia

Exotic Things:
Arrythmogenic Right Ventricular Dysplasia (epsilon waves, flipped t waves V1-V3)

Brugada (RBBB, STE, V1-V3)

Left Ventricular Hypertrophy (marked high voltage)

Pulmonary Embolism (Right axis shift, S1Q3T3, RBBB, Deep flipped t waves V1-V3)

QT too long / too short (Qt > 1/2 RR)

Wolf-Parkinson White