ED management of pediatric syncope: searching for a rationale

The aim of this study was to evaluate emergency department (ED) management of childhood syncope, focusing on diagnostic tests ordered, whether a reason for specific testing was recorded, and hospital admission rates.

We reviewed ED records of patients aged 5 to 20 years who presented to a community hospital ED with syncope or near-syncope over a 1-year period (April 1, 2004, to March 31, 2005). Patient charts were nonelectronic (paper). We reviewed the elements of the recorded history and physical examination for each patient. The specific tests ordered in the ED were classified into 3 general testing categories for each patient as follows: (1) simple testing, with a hospital charge of $100 or less per test; (2) expanded testing, more than $100 per test, with a recorded explanation; and (3) expanded testing without a recorded explanation.

The charts of 140 patients were reviewed. Of these, we excluded 27 based on exclusion criteria, including history of neurologic disorders. The mean age of the remaining 113 patients was 14.8 +/- 3.3 years. Most (80%) presented with syncope; 20% had near-syncope. Ten percent were admitted to the hospital, over half for an electrocardiogram (ECG) interpreted as abnormal by an ECG machine and/or the ED staff. Overall, 17.5% of patients had simple testing, 32.5% had expanded testing with explanation, and 50% had expanded testing without explanation. Patients with syncope were more likely than patients with near-syncope to be in the expanded testing category (P < .008). The most commonly ordered tests in the ED in order of decreasing frequency were electrolytes (90%), ECG (85%), complete blood count (80%), urinalysis, urinary drug screen, or urinary human chorionic gonadotropin (76%), head computed tomography (CT, 58%), and chest x-ray (37%). The most expensive of these tests was the head CT; all head CT results were negative.

A relatively high number of our subjects were admitted (10%), most often because of questions raised by the ECG. Although an ECG is widely recommended for pediatric syncope presenting to the ED, this suggests that ECG interpretation by a pediatric cardiologist would be helpful before the decision to admit is made. In addition, 58% of our subjects had a head CT in the ED; all CT results were negative. This high percentage of head CTs for pediatric syncope has not been previously reported.