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CCS/CPCA 2016 Position Statement: The Approach to Syncope in the Pediatric Patient

Background Transient loss of consciousness is a common problem encountered in primary and acute care A peak incidence occurs in pre- and adolescence Most syncope is vasovagal and is benign and requires only a thorough history and physical to diagnose Most patients are over-investigated

Background (cont’d) Simple strategies are effective at reducing recurrence in most No Canadian pediatric guidelines for this common problem International adult and pediatric guidelines Sheldon 2015

Methods Proposal to CCS from CPCA GRADE methodology Co-chairs and primary and secondary panels appointed Very inclusive search strategy: 4307 articles Screened for relevance, English and French 296 full text review, 231 included Recommendations drafted and voted on Draft to secondary panel, revised, guidelines committee, revised, Executive, CJC, revised

Recommendation #1 We recommend a detailed history in all cases (see Table 2). (Strong recommendation, Moderate Quality Evidence)

Table: History and Physical

Recommendation #2 A focused physical examination should always be performed. (Strong recommendation, Low Quality Evidence)

Recommendation #3 For all children with atypical syncope or who have additional risk factors (see Table 5), we recommend a 12-lead electrocardiogram. (Strong recommendation, Low Quality Evidence)

When to do an ECG in Syncope History is not diagnostic of VVS. No prodrome before syncope. Mid-exertional event (e.g., swimming). Syncope triggered by loud noise or startle Family history of sudden death or heart disease in young individuals. Abnormal cardiac exam New medication with potential cardiac side effects (e.g., https://crediblemeds.org/)

ECG in Syncope Van Dorn Pediatr 2011

Table: ECG findings in syncope

Teach the tangent Postema Heart Rhythm 2008

Recommendations #4 & 5 For children presenting with a history typical of vasovagal syncope, no family history of arrhythmia, and normal physical exam, we suggest that further cardiac investigations not be performed. For children presenting with a history typical of vasovagal syncope, no family history of epilepsy, and normal physical examination, we suggest that an EEG or neuroimaging not be performed. (Strong recommendation, Low Quality of Evidence)

Recommendation #6 For children with typical vasovagal syncope, we recommend a conservative strategy of education, avoidance of provoking factors, increase in salt and fluid intake, and teaching physical maneuvers as a preventative and rescue strategy. (Strong recommendation, Low Quality of Evidence)

Recommendation #7 For children with highly symptomatic vasovagal syncope resistant to conservative measures, we suggest treatment with midodrine during active hours. (Strong recommendation, Low Quality of Evidence)

Recommendation #8 For children who have syncope associated with a history atypical for vasovagal syncope, a family history of arrhythmia or epilepsy, relevant abnormalities on physical exam, or an abnormal EKG, we recommend referral to a specialist with expertise in syncope. (Strong recommendation, Low Quality of Evidence)

A call to action We need to work together to gather data We have an opportunity to introduce counter-pressure teaching We can prospectively evaluate ECG utility