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Abstract
Background
To evaluate the causes of syncope in the pediatric population, positive and negative etiological predictors, and examine the utilization and utility of specialist evaluations and diagnostic testing in the workup of syncope.
Methods
Retrospective chart review in a tertiary academic center.
Results
750 pediatric patients presenting with syncope over a 5-year period were identified. 76% of patients received electrocardiograms, 36.9% had cardiology evaluations, 23.1% had neurology evaluations, 33.7% had echocardiograms, over 20% underwent neuroimaging, 23.5% had electroencephalograms (EEGs), and 73.6% had additional testing. Over half of all patients initially presented to the emergency department (52%), where they were significantly more likely to get head CTs (OR: 2.49) and additional testing (OR: 3.42). The majority of all testing and evaluations resulted in a diagnosis of neurally mediated syncope (NMS) (74%), while only 2.3% and 1.6% were attributed to cardiac and seizure diagnoses, respectively. Patients with a seizure diagnosis were significantly more likely to report shaking, abnormal movements, post-ictal confusion, and a family history of seizures; Patients with a cardiac diagnosis were significantly more likely to report symptoms with exertion, associated chest pain or palpitations, and an abnormal cardiac history.
Conclusions
Our study demonstrates an opportunity to improve the variability and cost of care in pediatric patients presenting with syncope, as a majority of specialist evaluations, cardiac testing, neuroimaging, and EEGs are not helpful in determining etiology of syncope. We identified positive and negative predictors of more serious etiologies that can assist in the development of guidelines for managing pediatric syncope.
Article Details
Copyright (c) 2020 Arayamparambil C Anilkumar, Mary Elizabeth Reed Shenk
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References
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- Fischer JW, Cho CS. Pediatric Syncope: Cases from the Emergency Department. Emergency Medicine Clinics of North America. 2010; 28(3):501-516. doi:10.1016/j.emc.2010.03.009.
- Strieper MJ. Distinguishing Benign Syncope from Life-Threatening Cardiac Causes of Syncope. Seminars in Pediatric Neurology. 2005; 12(1):32-38. doi:10.1016/j.spen.2005.01.001.
- Moodley M. Clinical Approach to Syncope in Children. Seminars in Pediatric Neurology. 2013; 20(1):12-17. doi:10.1016/j.spen.2012.12.003.
- Moya A, Sutton R, Ammirati F, et al., Task Force for the Diagnosis and Management of Syncope, European Society of Cardiology (ESC), European Heart Rhythm Association (EHRA), Heart Failure Association (HFA), Heart Rhythm Society (HRS). Guidelines for the diagnosis and management of syncope (version 2009). Eur Heart J. 2009; 30(21):2631–2671.
- Strickberger SA, Benson DW, Biaggioni I, et al., American Heart Association Councils on Clinical Cardiology, Cardiovascular Nursing, Cardiovascular Disease in the Young, and Stroke, Quality of Care and Outcomes Research Interdisciplinary Working Group, American College of Cardiology Foundation, Heart Rhythm Society, American Autonomic Society. AHA/ACCF Scientific Statement on the evaluation of syncope. Circulation. 2006; 113(2):316–327
- National Institute for Health and Clinical Excellence. Transient loss of consciousness (“blackouts”) management in adults and young people. NICE clinical guideline 109. NICE, London; 2010 http://guidance.nice.org.uk/CG109/NICEGuidance/pdf/English. Accessed June 23, 2018.
- Guse SE, Neuman MI, O’Brien M, et al. Implementing a Guideline to Improve Management of Syncope in the Emergency Department. Pediatrics. 2014; 134(5):e1413-e1421.
- Sanatani S, Chau V, Fournier A, Dixon A, Blondin R, Sheldon R.S. Canadian Cardiovascular Society and Canadian Pediatric Cardiology Association Position Statement on the Approach to Syncope in the Pediatric Patient. Canadian Journal of Cardiology 2017, 33 (2), pp. 189-198. https://doi.org/10.1016/j.cjca.2016.09.006
- Raucci U, Scateni S, Tozzi AE, Drago F, Giordano U, Marcias M, Faa F, Reale A. The availability and the adherence to pediatric guidelines for the management of syncope in the Emergency Department. J Pediatr. 2014 Nov; 165(5):967-72.e1. doi: 10.1016/j.jpeds.2014.06.064. Epub 2014 Aug 6.
- Roston, Thomas M. et al. A Population-Based Study of Syncope in the Young. Canadian Journal of Cardiology 2018; 34(2):195 - 201
- Shen W-K, Sheldon RS, Benditt DG, Cohen MI, Forman DE, Goldberger ZD, Grubb BP, Hamdan MH, Krahn AD, Link MS, Olshansky B, Raj SR, Sandhu RK, Sorajja D, Sun BC, Yancy CW, 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope, Journal of the American College of Cardiology. 2017. doi: 10.1016/j.jacc.2017.03.003
References
Friedman NR, Ghosh D, Moodley M. Syncope and paroxysmal disorders other than epilepsy. In: Swaiman KF, Ashwal S, Ferriero DM, Schor NF. eds. Swaiman's Pediatric Neurology: Principles and Practice. 5th ed. Philadelphia: Elsevier Saunders; 2012:905-925.
Fischer JW, Cho CS. Pediatric Syncope: Cases from the Emergency Department. Emergency Medicine Clinics of North America. 2010; 28(3):501-516. doi:10.1016/j.emc.2010.03.009.
Strieper MJ. Distinguishing Benign Syncope from Life-Threatening Cardiac Causes of Syncope. Seminars in Pediatric Neurology. 2005; 12(1):32-38. doi:10.1016/j.spen.2005.01.001.
Moodley M. Clinical Approach to Syncope in Children. Seminars in Pediatric Neurology. 2013; 20(1):12-17. doi:10.1016/j.spen.2012.12.003.
Moya A, Sutton R, Ammirati F, et al., Task Force for the Diagnosis and Management of Syncope, European Society of Cardiology (ESC), European Heart Rhythm Association (EHRA), Heart Failure Association (HFA), Heart Rhythm Society (HRS). Guidelines for the diagnosis and management of syncope (version 2009). Eur Heart J. 2009; 30(21):2631–2671.
Strickberger SA, Benson DW, Biaggioni I, et al., American Heart Association Councils on Clinical Cardiology, Cardiovascular Nursing, Cardiovascular Disease in the Young, and Stroke, Quality of Care and Outcomes Research Interdisciplinary Working Group, American College of Cardiology Foundation, Heart Rhythm Society, American Autonomic Society. AHA/ACCF Scientific Statement on the evaluation of syncope. Circulation. 2006; 113(2):316–327
National Institute for Health and Clinical Excellence. Transient loss of consciousness (“blackouts”) management in adults and young people. NICE clinical guideline 109. NICE, London; 2010 http://guidance.nice.org.uk/CG109/NICEGuidance/pdf/English. Accessed June 23, 2018.
Guse SE, Neuman MI, O’Brien M, et al. Implementing a Guideline to Improve Management of Syncope in the Emergency Department. Pediatrics. 2014; 134(5):e1413-e1421.
Sanatani S, Chau V, Fournier A, Dixon A, Blondin R, Sheldon R.S. Canadian Cardiovascular Society and Canadian Pediatric Cardiology Association Position Statement on the Approach to Syncope in the Pediatric Patient. Canadian Journal of Cardiology 2017, 33 (2), pp. 189-198. https://doi.org/10.1016/j.cjca.2016.09.006
Raucci U, Scateni S, Tozzi AE, Drago F, Giordano U, Marcias M, Faa F, Reale A. The availability and the adherence to pediatric guidelines for the management of syncope in the Emergency Department. J Pediatr. 2014 Nov; 165(5):967-72.e1. doi: 10.1016/j.jpeds.2014.06.064. Epub 2014 Aug 6.
Roston, Thomas M. et al. A Population-Based Study of Syncope in the Young. Canadian Journal of Cardiology 2018; 34(2):195 - 201
Shen W-K, Sheldon RS, Benditt DG, Cohen MI, Forman DE, Goldberger ZD, Grubb BP, Hamdan MH, Krahn AD, Link MS, Olshansky B, Raj SR, Sandhu RK, Sorajja D, Sun BC, Yancy CW, 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope, Journal of the American College of Cardiology. 2017. doi: 10.1016/j.jacc.2017.03.003