Protected: ECG Red flags

PEMBLOG red flags syncope

It happened in a child who is under 8 years old

This one takes a good history. Think about a toddler who has a report of loss of consciousness. If you take a really good history you’ll probably establish that it was a breath holding spell, which is technically a syncopal event, and usually due to vagal mechanisms. I did a podcast on breath holding spells if you are interested.

It was during exercise

This is one that we should take a little time to explore on history. Obviously it is worrisome if the patient syncopizes while running in a cross country meet. During exercise doesn’t mean that you have to be actively running, lifting weights etc,. It just means that one was exerting themselves and then they fainted. Obviously the big diagnosis to worry about here is hypertrophic obstructive cardiomyopathy. But anything that limits ventricular outflow (aortic stenosis) is on the table as well.

It was preceded by chest pain

Though these symptoms sometimes occur with vasovagal syncope, a carful history can help you get at this symptom. Remember, most kids will describe lightheadedness, visual changes etc,. before they fainted. Chest pain is actually relatively rare.

It was accompanied by significant physical injury from a sudden fall

Patients with syncope often go down quickly, but many are witnessed, and helped to the ground. Or gently catch themselves – and slump to the ground. Patients who sustain major trauma (a clinically important brain injury) went down hard and the event may have been sudden, and potentially worrisome.

There was a near drowning

This one is relatively rare (fortunately) but if someone faints and almost drowns then worry that something seriously happened. First, you should wake up if you go under water because of protective responses. And second, if you don’t anoxic injury can set in relatively quickly.

There was seizure activity with a postictal state

Remember, up to 40% of people who faint will convulse. But most recover very quickly. A patient who took longer than 20-30 minutes to recover should cause you to think a little more about what lead to the episode of loss of consciousness and why the patient didn’t recover as quickly. Please check out my post on convulsive syncope for helpful information, including a fantastic video that demonstrates the myriad of different abnormal movements that occur following syncope.

There are focal neurologic findings after the syncopal event

This one can go hand in hand with the previous one. You must do a good neurologic exam. Make sure to differentiate from pain caused by an injured wrist for instance, from somebody with asymmetric weakness. Patients who have syncope should not have an abnormal neurologic examination.