Abnormal motor activity is more likely to be seen with seizures. Seizures, in contrast, result in prolonged loss of consciousness (at least several minutes) with a delay in return to the patient's normal baseline mental state. In a child with syncope, the period of unconsciousness is brief, lasting only seconds, followed by a rapid recovery to normal mental status. Distinguishing between a seizure disorder and the seizure-like activity that can be seen after a breath-holding spell is sometimes difficult. Seizures are the primary cause of neurologic syncope. Finally, recurrent syncope of unexplained etiology, even with a negative emergency department evaluation, should be referred to a pediatric cardiologist. In addition, a child who has the findings of congestive heart failure, myocarditis, or cardiomyopathy (tachypnea, enlarged liver, enlarged heart, rub, rales) needs a complete cardiac evaluation. Any new onset murmur heard after a child has had a syncopal event requires evaluation. A systolic murmur enhanced by standing or the Valsalva maneuver may be due to IHSS. Physical findings suggestive of a cardiac etiology include a systolic ejection click, a harsh systolic ejection murmur over the base of the heart radiating to the carotids, and a palpable thrill in the suprasternal notch (all suggestive of aortic stenosis). A single ECG in the emergency department is not enough such children should be admitted for monitoring. Particularly if a young child reports chest pain associated with dizziness, lightheadedness, or syncope, an evaluation for an arrhythmia is necessary. Chest pain in an adolescent is generally not serious, but in a young child palpitations may be reported as chest pain. A complete cardiac evaluation including an electrocardiogram (ECG), chest x-ray, and, if possible, an echocardiogram should be performed in the emergency department. Syncope associated with exercise is worrisome and should bring to mind conditions such as idiopathic hypertrophic subaortic stenosis (IHSS) associated with ventricular outflow obstruction. Historical factors suggestive of a cardiac etiology include a family history of sudden unexplained death (congenital, prolonged QT interval), prior history of Kawasaki disease (coronary artery insufficiency secondary to aneurysm formation), prior cardiac surgery (complete heart block or other arrhythmia), recent unexplained change in exercise tolerance associated with tachypnea or fever (myocarditis or cardiomyopathy), or known congenital pulmonary outflow obstruction ("tet" spell). Noncardiac causes can be further divided into neurologic, respiratory, autonomic, and metabolic etiologies.Ĭardiac syncope is usually caused by arrhythmias or ventricular outflow obstruction and is the most serious form of syncope in children. Cardiac causes are always worrisome noncardiac and unknown causes are less likely to be as serious. Vasovagal syncope is estimated to occur in 15 to 25 percent of adolescents.įor practical purposes the causes can be divided into cardiac, noncardiac, and unknown etiology. However, at least 15 percent of children will experience an episode of syncope brought to the attention of a physician before they complete adolescence, and approximately 1 percent of pediatric admissions are for the evaluation of a syncopal episode. The incidence of childhood syncope is undoubtedly underreported. Syncope in children must be evaluated carefully because it can be the sole manifestation of a serious underlying condition. The most important task is answering the clinical question Does this represent a potentially lethal condition or one with significant morbidity? Fortunately in most cases of pediatric syncope the answer to this question will be No, but this is precisely the clinical dilemma. Other causes of altered mental status such as shock, vertigo, drug intoxication, sepsis, coma, and seizures must be excluded. Not uncommonly, seizure-like activity may follow a primary syncopal event. A reversible, short-lived impairment of cerebral perfusion occurs. Syncope is a sudden, brief, and transient loss of consciousness associated with an inability to maintain normal muscle posture and tone. Syncope is common in children and most episodes go unreported. The Authors examined syncope and breath holding
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