Welcome to Facts on the Ground a new series brought to you by Natan Cramer, Pediatric Emergency Medicine fellow from the University of Pittsburgh. Facts on the Ground is designed to be a concise literature review that helps answer common clinical questions.
The primary objective was to evaluate the value of EKG in identifying cardiac causes of syncope and to establish an effect size for use in future prospective studies. The hypothesis is that there is a certain subset of pediatric patients who do not require an EKG as part of syncope ED evaluation.
A multicenter, retrospective descriptive study was performed in Spain and included children aged 0-14. Exclusion criteria included patients with known cardiac disease, loss of consciousness related either to head trauma, poisoning, seizure, hypoglycemia or near-syncopal patients. Syncope was defined as a sudden, brief loss in tone and consciousness with quick, full recovery.
440 children were diagnosed with syncope during the study period. EKG’s were performed on 197 of these patients (44.7%). 14.7% of these patients had episodes that were linked with physical exertion. Physical exam was normal in 96.4% of patients who underwent EKG. Minor findings were seen in 19.2% of patients with by far the most prevalent finding being an incomplete right bundle branch block (comprising 78.9% of minor findings). No major EKG abnormality was discovered. No patient was found to have a specific undiagnosed cardiac cause of syncope.
The study is dealing with a relatively more homogenous population compared to the United States. It is unknown how many of the patients later underwent echocardiogram to definitely rule out structural cardiac disease. Thus, further information from subsequent cardiology visits could further establish the diagnostic accuracy and predictive utility of ED EKG. Further information about true disease diagnosed on outpatient follow up could help define the sensitivity and specificity.
The Bottom Line
A cardiac cause of syncope is overall rare. EKG use for syncope work-up among ED providers in their cohort is variable.