Syncope Evaluation Algorithm¶

Initial Assessment¶

flowchart TD
    A[Pediatric Syncope] --> B{History & PE}
    B --> C[Typical Vasovagal Features?]

    C -->|Yes| D[Low Risk\nReassurance + Education]
    C -->|No/Unclear| E[ECG Required]

    E --> F{ECG Abnormal?}
    F -->|Yes| G[Cardiology Referral]
    F -->|No| H{Red Flags Present?}

    H -->|Yes| G
    H -->|No| I{Exercise-related?}

    I -->|Yes| J[Echo + Exercise Test]
    I -->|No| D

📋 Text Version (if diagram doesn't render)

**Initial Syncope Assessment** 1. **Pediatric Syncope** → History & PE → Typical vasovagal features? - **YES** → Low Risk - Reassurance + Education - **NO/Unclear** → ECG Required 2. **ECG** → Abnormal? - **YES** → Cardiology Referral - **NO** → Red Flags Present? - **YES** → Cardiology Referral - **NO** → Exercise-related? - **YES** → Echo + Exercise Test - **NO** → Reassurance + Education

Red Flags Requiring Cardiology Evaluation¶

Category	Specific Findings
History	Exertional syncope, syncope with swimming, syncope while supine, palpitations before syncope, chest pain, family history of sudden death <50y
Physical Exam	Abnormal cardiac exam (murmur, gallop), hypertension, features of Marfan/genetic syndrome
ECG	Long QTc (>460ms), short QTc (<340ms), WPW (delta wave), Brugada pattern, significant arrhythmia, deep Q waves, RBBB + LAD (AV canal), extreme axis

Typical Vasovagal Syncope Features¶

Prodrome: - Lightheadedness, visual changes - Nausea, warmth, diaphoresis - Gradual onset (seconds to minutes)

Setting: - Standing, especially prolonged - Hot/crowded environment - Emotional stress, pain, blood draw - Post-exercise (NOT during)

Recovery: - Brief LOC (<1 minute) - Rapid recovery (no confusion) - No post-ictal symptoms

Exertional Syncope Workup¶

flowchart TD
    A[Exertional Syncope] --> B[ECG]
    B --> C[Echo]
    C --> D[Exercise Stress Test]

    D --> E{All Normal?}
    E -->|Yes| F[Consider Holter\nMay be benign]
    E -->|No| G[Based on findings:]

    G --> H[HCM → Risk stratify]
    G --> I[LQTS → Beta-blocker]
    G --> J[CPVT → Restrict sports]
    G --> K[AAOCA → CT/MRI]
    G --> L[Arrhythmia → EP consult]

📋 Text Version (if diagram doesn't render)

**Exertional Syncope Workup** 1. **Exertional Syncope** → ECG → Echo → Exercise Stress Test 2. **All Normal?** - **YES** → Consider Holter, may be benign - **NO** → Based on findings: - HCM → Risk stratify - LQTS → Beta-blocker - CPVT → Restrict sports - AAOCA → CT/MRI - Arrhythmia → EP consult

ECG Interpretation Checklist for Syncope¶

Parameter	Normal	Action if Abnormal
QTc	<450ms	>460ms: LQTS evaluation
PR interval	Age-appropriate	Short + delta wave: WPW
QRS	Narrow	Wide: BBB, consider cardiomyopathy
T waves	Upright (V5-V6)	Inversion: HCM, ARVC
ST segments	Isoelectric	Elevation V1-V2: Brugada
Q waves	Small, narrow	Deep/wide: HCM, ALCAPA

Treatment of Vasovagal Syncope¶

First-Line (Class I)¶

Education and reassurance
Hydration - increase fluid intake
Salt intake - if tolerated
Avoid triggers - prolonged standing, dehydration

Physical Counter-Pressure Maneuvers¶

Leg crossing with muscle tensing
Handgrip with arm tensing
Squatting at prodrome onset

NOT Recommended (Class III: No Benefit)¶

Beta-blockers - No proven efficacy in pediatric vasovagal syncope
Midodrine - Limited evidence in children

Differential Diagnosis¶

Feature	Vasovagal	Cardiac	Seizure
Prodrome	Yes (seconds)	None or palpitations	Aura (variable)
Setting	Standing, heat	Exertion, supine OK	Any
Duration	<1 min	<1 min	Variable
Recovery	Rapid	Rapid	Post-ictal confusion
Injury	Usually minor	Can be severe	Can be severe
Incontinence	Rare	Rare	Common

When to Consider Holter/Event Monitor¶

Palpitations preceding syncope
Recurrent unexplained syncope
Syncope despite normal initial workup
Family history of arrhythmia

When to Consider Tilt Table Test¶

Recurrent syncope despite conservative measures
Atypical features but normal cardiac workup
Not required for classic vasovagal presentation
Limited diagnostic value in children (high false positive rate)

Risk Stratification Summary¶

Low Risk (Reassurance)¶

Classic vasovagal features
Normal ECG
Normal cardiac exam
No family history of sudden death
No exertional component

Intermediate Risk (Further Workup)¶

Atypical features
Normal ECG but concerning history
Recurrent episodes
Need for sports clearance

High Risk (Urgent Cardiology)¶

Exertional syncope
Syncope with chest pain
Syncope while swimming
Abnormal ECG
Family history of sudden death <50y
Known cardiac disease

Documentation Template¶

Syncope Evaluation:
- Episode details: [timing, duration, position, activity]
- Prodrome: [yes/no, description]
- Triggers: [standing, heat, emotional, exertional]
- Recovery: [immediate/gradual, confusion]
- Prior episodes: [frequency, similar features]
- Family history: [sudden death, arrhythmia, cardiomyopathy]
- ECG: [rate, rhythm, intervals, morphology]
- Assessment: [vasovagal vs cardiac vs other]
- Plan: [reassurance/workup/referral]