Syncope is a relatively sudden, brief, self-limited loss of postural tone and consciousness followed by rapid spontaneous recovery without any neurologic sequelae.1-3 Syncope is a common pediatric problem, representing 1% to 3% of all pediatric emergency department (ED) visits and 6% of hospital admissions. It has an estimated population incidence of 10% to 15%.4,5 In children and adolescents, syncope is substantially more common in females (65.6% female, 34.4% male). Although syncope can occur in any demographic group throughout the world, in North America, those who seek medical care for this complaint are more likely to be White and have private insurance.1,5,6 For instance, one study found that 54% of pediatric syncope patients presenting to an East Coast ED were White, whereas 22% were Latino, 16% were Black, and 2% were Asian.7 Of these pediatric ED patients, 68% had private primary insurance and 32% had public insurance.7 Syncope, although not a serious illness and typically benign in etiology, can have high healthcare costs. In a study of one cohort, pediatric syncope accounted for $1.1 million dollars of testing over a 2-year period, with an average cost of $2488 per patient.1 Much of this testing was unnecessary due to the benign nature of syncope. In addition to being common and having high healthcare costs, syncope deserves attention because it significantly impacts quality of life. Pediatric syncope patients are known to have Pediatric Quality of Life Inventory total scores as low as children and adolescents with other chronic illnesses such as diabetes, asthma, obesity, and end-stage renal disease.6,8-10
To treat this common condition effectively, while simultaneously being mindful of cost and quality-of-life concerns, a comprehensive history and physical examination should be performed with particular attention given to red flags that signify more serious pathologies masquerading as syncope. In this chapter, we discuss the critical components of this evaluation, the salient red flags and summarize this information in a useful algorithm that has served as the framework for our multidisciplinary syncope clinic. Finally, we discuss treatment and educational tools that can rapidly address symptoms, provide reassurance to families, and reduce unnecessary healthcare utilization.
PATHOPHYSIOLOGY AND TERMINOLOGY
Neurocardiogenic syncope (NCS) is triggered by a fall in systemic arterial pressure created by a combination of increased vagal tone (bradycardia) and decreased sympathetic tone (vasodilation).1-5 This decreases venous return and, hence, cardiac output, resulting in cerebral hypoperfusion and subsequent syncope. Vasovagal syncope, neurally mediated syncope, vasodepressor syncope, and orthostatic intolerance are synonyms for NCS.
To ensure that syncope is due to benign causes and not indicative of a more ominous health problem, it is imperative to conduct a thoughtful and thorough evaluation considering a broad differential of cardiac, neurologic, psychiatric, and other causes.5 The foundation ...