Fifteen-minute consultation on limiting investigations in the fainting child

Abstract

Syncope can be a dramatic and frightening experience for the patient and onlookers. It can also be a confusing area for doctors, with a lack of diagnostic certainty and a differential that ranges from the completely benign to the lifethreatening. This is a tricky area for clinicians, who can find it difficult to reassure their patients and their families. The aim of this article is to present a clear scheme for appropriate investigation and referral of paediatric patients with syncope. The aim of investigations in such cases should be to confirm or exclude serious, life-threatening causes of syncope.

Missed or Delayed Diagnosis of Heart Disease by the General Pediatrician

“…Reflex syncope, including 'vasovagal' syncope or simple fainting is attributed to reflex (vagal) nervous activity resulting in slow heart rate and hypotension and represents the most common diagnosis [113]. Another cause is orthostatic hypotension which represents an impairment of systemic vascular resistance due to a variety of primary and secondary causes concerning the autonomic nervous system [114]. Features suggestive of reflex syncope include nausea, vomiting, after an emotionally stressful event, following prolonged standing in a hot, crowded area, during or after a meal, after exercise and head rotation [114].…”

“…Another cause is orthostatic hypotension which represents an impairment of systemic vascular resistance due to a variety of primary and secondary causes concerning the autonomic nervous system [114]. Features suggestive of reflex syncope include nausea, vomiting, after an emotionally stressful event, following prolonged standing in a hot, crowded area, during or after a meal, after exercise and head rotation [114]. Syncope due to orthostatic hypotension occurs following standing from supine, sitting or squatting position, standing after exercise, prolonged standing in a hot environment and secondary to commencement of vasoactive medications [114].…”

“…Features suggestive of reflex syncope include nausea, vomiting, after an emotionally stressful event, following prolonged standing in a hot, crowded area, during or after a meal, after exercise and head rotation [114]. Syncope due to orthostatic hypotension occurs following standing from supine, sitting or squatting position, standing after exercise, prolonged standing in a hot environment and secondary to commencement of vasoactive medications [114]. Orthostatic hypotension is defined as a decrease in systolic blood pressure of 20 mm Hg or a decrease in diastolic blood pressure of 10 mm Hg after three minutes of standing, compared with blood pressure in the supine or sitting position.…”

Syncope: Not for the faint hearted

“…Leading the list of red flags is occurrence during exercise. While syncope during exercise requires referral and investigation, that which occurs immediately after exercise is generally benign, so clarity in the history is important. Syncope during exercise is the leading indication for exercise testing in post‐syncopal children.…”

“…The aortic stenosis ejection systolic murmur is loudest in the aortic area and myocarditis is suggested by a disproportionate tachycardia with or without other signs of heart failure, often with chest pain and a history of recent viral illness. An abnormal examination is more likely to lead to abnormalities being detected by echocardiography …”