Detailed History:

Event history: duration of episode, presence of prodrome, activities preceding event, any injuries during event

NCS specific: dehydration factors, position change preceding event, emotional/painful stimulus, warm environment, visual changes (tunnel vision or visual blackout), or muffled hearing

Cardiac specific: chest pain or palpitations immediately prior to syncope, syncope during exercise, syncope without warning

Neurologic specific: post ictal state of confusion lasting minutes to hours, rhythmic bilateral jerking accompanied with fecal/urinary incontinence, lateral tongue biting, and focal signs may indicate seizure and not syncopal convulsion

PMH: any history of syncope, congenital heart disease, cardiac surgery, Kawasaki disease, epilepsy, anxiety/depression, suicidalideation, current medications, recent growth spurt, menstrual history, or rapid weight loss

PFH: cardiac (cardiomyopathy, arrhythmia, placement of a pacemaker or defibrillator, sudden cardiac death < 50 years, death from unknown cause < 50 years, SIDs), neurologic (seizures – include type, age of onset, type and duration of treatments, epilepsy associated deaths, multigenerational seizure syndromes, migraines, sleep disorders and/or neurovascular diseases)

Comprehensive Physical Exam:

*Perform a thorough physical exam including vital signs with specialized focus on the following systems

Neurologic: GCS, cranial nerves, fundoscopic exam to rule out increased ICP and testing of vestibular system

Cardiac: heart rate, rhythm, auscultation for murmur, palpation of precordium, orthostatic vital signs

Testing:

- Non contrast head CAT scan if concern for TBI

-Electrocardiogram (ECG) for all patients

-Consider lab work (electrolyte panel, complete blood count, toxin/drug screen, pregnancy test in post menarchal females)

Specialized Testing:

NCS: Tilt-table test (patient is placed on a table and tilted to ~70 degrees for ~45 minutes while being monitored by ECG and BP-the test is used to create an artificial orthostatic stress that can provoke a drop in BP and HR)

Cardiac concern – Cardiology consult and often echocardiogram (echo), Holter monitor, stress test

Neurologic concern – Neurology consult and may require electroencephalogram (EEG)

Definition

• Syncope has been defined as a transient, self-limited loss of consciousness and postural tone. The recovery is usually spontaneous, rapid, and complete without any neurological sequelae.

Incidence

• Some reports estimate 35% of children experience syncope at least once in their lifetime

• Some reports estimate 15% of children will have an episode of syncope before they reach their 18th birthday

• Most reviews of syncope report it’s more common in girls than boys

• The peak incidence is 15-19 years of age

• Etiology not identified in 26 – 40% of patients

Introduction

Evaluation of a patient following an unwitnessed fall from a syncopal episode can pose a diagnostic dilemma for the Pediatric Surgery/Trauma team.

The cause of syncope may or may not be related to the trauma but the workup is often labor intensive and a source of stress for families

History:

Event history: G. S. 15 y/o male found down by mother with plastic basketball hoop laying on top of him. He recalls feeling “dizzy” prior to fall and is amnestic to event. Per mother - no seizure activity, no urinary/fecal incontinence, no tongue biting/blood in mouth.

PMH/PSH: chest pain and palpitations for 2 years, anxiety and depression, stressors including recent break up/new school/new gang members on bus, prior ETOH use but no recent ETOH/drug usage, plays basketball/baseball/football

FH: hypertension and hyperlipidemia, brother with Osler Weber Rendu syndrome with “3 holes in his heart” who underwent cardiac surgery ~ 3 years ago after a TIA.

Physical exam: VS: BP 124/69 mmHg | Pulse 107 | Temp 36.4 ° C (97.5 ° F) | Resp 18 | Ht 165 cm (64.96 “) | Wt 153 lb | BMI 25 | SpO2 96% General: awake, alert, HEENT: NCAT, PERRL bil Neck: supple, collar cleared Airway: natural Heart/CV: RRR, normal S1, normal S2 with physiologic splitting, no murmur, normoactive precordium, no rubs, clicks or gallops Lungs/Chest: CTA bilateral Abdomen: soft, NDNT, no hepatosplenomegaly Extremities: no edema, no cyanosis, no clubbing, brisk capillary refill, upper and lower extremity pulses normal Neuro: CN II-XII intact, interactive, initial GCS 5 at OSH, then 11 arrival LCH ED, progressively back to 15, (+) H/A

Workup: Head/Neck CT – negative, urine tox screen – negative, CBC and BMP – WNL, troponin <0.02, EEG – negative, ECG – ST elevation and LVH, telemetry – sinus rhythm with intermittent sinus bradycardia, Echo -negative, exercise stress test – excellent exercise endurance with excellent VO2 max and HR response but exaggerated BP response -consult Neurosurgery, Neurology, Cardiology and Psychiatry

Diagnosis: Syncopal episode (likely cardiac in origin – Brugada syndrome) – discharged home with cardiology follow up

-MRI scheduled as outpatient to evaluate for cardiomyopathy

-exercise restrictions until follow up

- if MRI abnormal and palpitations present, may consider implantable loop recorder

Case Study: G. S. 15 y/o male

ReferencesAnderson, J. B., Willis, M., Lancaster, H., Leonard, K., and Thomas, C. (2016). The evaluation

and management of pediatric syncope. Pediatric Neurology, 55, 6-13. Arbuthnot, M. K., Mooney, D. P., and Glenn, I. C. (2017). Head and cervical spine evaluation

for the pediatric surgeon. Surgical Clinics of North America.97, 35-38. Collins, N., Miller, R., Kapu, A., Martin, R., Morton, M., Forrester, M., Atkinson, S., et al.

(2014). Outcomes of adding acute care nurse practitioners to a Level I trauma service withthe goal of decreased length of stay and improved physician and nursing satisfaction. Journal of Trauma Acute Care Surgery. 76, 353-357.

Phelps, H. M., Sachdeva, R., Mahle, W. T., McCracken, C. E., Kelleman, M., McConnell, M., etal (2016). Syncope best practices: A syncope clinical practice guideline to improve quality.Congenital Heart Disease. 11, 230 – 238.

SYNCOPAL WORKUP IN PEDIATRIC TRAUMA PATIENTSLaurie Sands, RN, MSN, CPNP PC/AC

Ann & Robert H. Lurie Children’s Hospital of Chicago

Objectives

Objective 1:Participants will be able to identify cardiac causes of syncope

Objective 2:Participants will be able to identify neurological or neurosurgical causes of syncope

Objective 3: Participants will understand the importance of collaboration of multiple care providers in the workup of the pediatric trauma patient following a syncopal episode

Background

Results: Workup

Categories of Syncope:• Neurocardiogenic Syncope (NCS) or (Vasovagal): most common* - 60 to 85% of syncopal

cases - inappropriate vasodilation leads to neurally mediated systemic hypotension and subsequent decreased cerebral blood flow and syncope - causes include – extended period in upright position, dehydration, vagal trigger, or external stimuli (pain or emotional upset)

• Cardiac: 2 to 6 % of syncopal cases - result of sudden decrease in cardiac output which leads to decreased cerebral perfusion and syncope – causes include - dysrhythmias, structural/functional heart defects, and vascular heart abnormalities

• Neurological: 12 to 90% of syncopal episodes will be accompanied by a convulsive activity following loss of consciousness such as stiffening or jerking of the extremities - most common causes of loss of consciousness that mimic syncope include seizures, vascular events, disruption in CSF circulation, and sleep disorders

• Neurosurgical: traumatic brain injury (TBI)

• Psychiatric: Up to 26% of loss of consciousness may be linked to psychiatric disorders –causes include - conversion disorder, Munchausen syndrome, somatization disorder, anxiety, depression, and panic attacks

Collaboration:• Collaboration is key in the approach of evaluating pediatric trauma patients following a syncopal episode• Following the primary and secondary survey, specific causes and consultation of specialized services is often necessary• The trauma team serves in a unique role of initial stabilization and then communication among care teams to coordinate care and

transfer of the patient to the appropriate team