Syncope in the Young: Retrospective Review of Emergency Department Presentations

Background: Syncope is transient loss of consciousness due to global cerebral hypoperfusion, occurring in 1 in 5 children. 1-3% of visits to Paediatric Emergency services result from syncope or ancillary injury. Clinically challenging, acute unexplained episodes are compounded by lack of collateral history or fear of sinister pathology. Resulting over-investigation may occur, with increased burden on both patient and healthcare system.

Objective: This study sought to determine the current management practices of childhood syncope within a tertiary emergency department.

Methods: Retrospective review of presentations to TSCUH Emergency Department (January-December 2017). Symphony (Patient Information System was interrogated to extract cases with diagnostic codes: “Syncope”, “Presyncope”, “Vasovagal Episode” or “Faint” in 0-16-year olds. Information on demographics, presentation, event characteristics, clinical management and measures of healthcare utilisation were analysed. All data are reported as proportions, means+/-SD as appropriate and analysed in STATA14.0.

Results: Data from 104 patients diagnosed with syncope were analysed: mean age 11.5+/-3.4yrs; 73(70.2%) female. Family history was documented in 45(43.2%) cases. Normal physical examination in 101(97.1%); abnormalities noted in 3(2.9%) - cardiac murmur, bradycardia, hypotension. 66(63.5%) events were witnessed; 47(45.2%) were recurrent fainters. Event-related injuries were sustained in 26(25%). Key differentiating symptoms were undocumented in most cases. Events occurred largely in the standing position 57(54.8%), followed by situational syncope 14(13.5%). ECG was the most commonly performed investigation 86(82.7%), while more patients received urinalysis 29(27.9%) than lying/standing BP 20(19.2%). Referrals were initiated by parents in 73(70.2%) cases, 28(26.9%) were transported by ambulance. Average attendance duration was 3hrs33mins. Admission occurred in 4(3.9%) patients with additional 22(21.1%) referred for outpatient follow-up (highest referral rate to cardiology-50%).

Conclusion: Syncope is associated with varying levels of case complexity, resulting in high resource use. Adoption and implementation of International Clinical Guidelines which address these complex events should be considered, with proven positive impact on patient management.