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Syncope: Avoid the Knee-Jerk Echo :

April 12, 2016

That’s why Cannon and Wackel’s update on syncope in April Pediatrics in Review is a must-read for the pediatrician.

The limp child lying on the floor with a very slow pulse rate is frightening, especially to a parent confronting the situation for the first time.
That’s why Cannon and Wackel’s update on syncope in April Pediatrics in Review is a must-read for the pediatrician.

Syncope is a very common situation, especially in teens, and all of us have had to deal with the problem. The good news is that syncope is seldom cardiac in origin, although that is everyone’s first concern. Rather than making a reflex referral to a cardiologist, the pediatrician─even in a busy office─should take a detailed and careful history of the event.

A good differential point is that cardiac syncope due to ventricular tachydysrhythmia has no prodrome. Most young patients will tell you that they get dizzy when standing rapidly, and that before the faint they were aware of a headache, nausea, and often tunnel vision. The prodrome is miserable.

Patients, if honest, often will describe a limited fluid intake, consumption of caffeine, and will note their urine is cloudy or deep yellow. The athlete will go from class to track, not hydrate and faint after (not during) a long run.

The rare patient will tell you that they were aware of their surroundings, and observers will report that the patient’s eyelids were fluttering. This is the patient who is trying to get attention. It is never done without an audience.

Testing should be limited to an electrocardiogram. You just saved your patient about 10 grand in so doing. An echo is useless and, to quote a well-respected senior pediatric cardiologist from a cold state in the Midwest, tilt table testing is “not worth a bucket of warm spit.” The test is very uncomfortable, will be positive, and its main merit is ferreting out the patient who is not having true syncope.

Treatment with increased fluid intake is successful in most. The goal should be to have urine that is clear as tap water. Younoszai, Franklin, et al (1) showed that patients with positive tilt table results no longer were positive after intravenous infusion of saline. Then, Younoszai et al (2) surveyed patients in an intermediate term follow-up study and found that most were compliant with the regimen because they no longer suffered the awful prodrome and had no more episodes.

Cannon and Wackel’s review is excellent. Careful attention to it should minimize inappropriate referrals and testing.

1.Younoszai AK, Franklin WH, Chan DP, Cassidy SC, Allen HD. Oral Fluid Therapy – A Promising Treatment for Vasopressor Syncope. Arch Pediatr Adolesc Med. 1998;152:165-168.
2.Younoszai AK, Franklin WH, Chan DP, Cassidy SC, Allen HD. Intermediate-term followup of fluid therapy in patients with vasodepressor syncope. J Am Coll Cardiol. 1997;29(2):7745.
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