Understanding and Managing Neurally Mediated Syncope in the Adolescent

Abstract

Syncope and near-syncopal symptoms are common events in the adolescent population. Syncope is defined as the transient loss of postural tone and consciousness with spontaneous recovery. Although most syncopal events are benign, they can generate extreme anxiety in the adolescent and his or her family. The re-occurrence of these events can have a negative impact on an adolescent's participation in daily activities. Understanding the process of assessment, diagnosis, and management of these teens can enable the school nurse to augment initial assessment and to support the prescribed treatment plan. This knowledge then can be used to help allay the adolescent's anxiety and to support efforts at self-management. This article explores current literature in regards to etiology, diagnosis, and medical treatment, and advocates a self-management protocol for neurally mediated syncope in the adolescent population with support of that plan by the school nurse.

Neurally mediated syncope

“…Drugs, which are of limited use [1], include fludrocortisone to increase salt and fluid retention, and sympathomimetic agents such as ephedrine [5], beta-blockers [21], alpha agonists [22], and serotonin reuptake inhibitors [23]. As far as affected children are concerned, the school nurse will have an important role to play, so it is essential that she knows the possible treatment options [24]. There are doubts about the use of cardiac pacemakers in the treatment of neurally mediated syncope as va-sodilatation plays such an important part in causing this condition, attacks tend to occur in clusters over a short period, and affected patients are often young, and more research is needed into the criteria for their use [21].…”

The use of hormonal therapy in pediatric heart disease

“…This includes avoidance of triggering events, recognition of premonitory symptoms, physical maneuvers to prevent blood from pooling in the extremities and maintenance of adequate hydration. Patients are also instructed to avoid caffeinated drinks and to increase their daily salt intake (42, 45,46,56). When recurrent syncope is unresponsive to behavioral modification strategies, pharmacologic treatment may be recommended.…”

“…When recurrent syncope is unresponsive to behavioral modification strategies, pharmacologic treatment may be recommended. Multiple drug therapies have been employed with variable success, including the use of mineralocorticoid, beta-blockers, selective serotonin reuptake inhibitors, and alpha agonists (45,46,49,(56)(57)(58). The use of drug therapy for these patients is palliative and does not cure the tendency for recurrent syncope.…”

“…The use of mineralocorticoid therapy is generally the first choice for pediatric patients and among the first considerations in adults with recurrent neurocardiogenic syncope (40, 45,46,61,62). Its use in neurocardiogenic syncope is predicated on the principle of increasing central blood volume through the increase in sodium and fluid retention and is supported by results of tilt-table testing (62)(63)(64).…”

“…Syncope may be categorized by etiology as cardiogenic, neurogenic, cerebrovascular, orthostatic, metabolic, vagal, or psychiatric (42-44). When these specific etiologies have been excluded, syncope may then be classified as neurally mediated, also referred to as neurocardiogenic, autonomic, or vasovagal syncope (42, [44][45][46]. All of these terms are used to indicate a benign form of syncope and are occasionally referred to in a category of unexplained syncope, or syncope of unknown origin (42, [44][45][46].…”