Hot Seat #176: 15-year-old with syncope
Posted on: September 15, 2021, by : Walter Palmer
Tim Carr, MD, Children’s National Medical Center
HPI
A 15-year-old boy with history of epidural hematoma presented following a syncopal episode. Patient states he was cooking breakfast about 1 hour prior to arrival, inhaled in some smoke from the bacon, felt a wave of nausea, felt faint and passed out. The episode was witnessed and described as the patient “squirming” briefly on the floor. There was shaking of his arms and legs for seconds, but then resolved. Patient complained of mild nausea afterward but quickly back to baseline without seizure activity or post-ictal symptoms. Patient states he thinks he hit the back of his head but no other injuries. Complaining currently of mild occipital headache, but no persistent nausea. His mother states that he has not been eating or drinking very much recently. No history of seizures or syncope in the past. No preceding headache, chest pain or abdominal pain prior to the event, and no recent illness.
Patient has a history 8 years ago of head trauma with L frontal epidural hematoma requiring evacuation by neurosurgery which he has recovered well from with no secondary neurologic complications.
Medical History: L frontal epidural hematoma s/p craniotomy for evacuation
Surgical History: Craniotomy for evacuation of epidural hematoma
Allergies: No known drug allergies
Medications: None prescribed
Immunizations: UTD
ROS:
Constitutional symptoms: denies fever, denies chills, denies decreased appetite.
Skin symptoms: denies rash, denies bruising, denies infection.
Eye symptoms: denies redness.
ENMT symptoms: denies sore throat, denies nasal congestion.
Respiratory symptoms: denies shortness of breath, denies cough.
Cardiovascular symptoms: Syncope, denies chest pain, denies palpitations.
Gastrointestinal symptoms: Nausea, no abdominal pain, no vomiting, no diarrhea, no change in stool color.
Genitourinary symptoms: no hematuria.
Musculoskeletal symptoms: no Muscle pain, no Joint pain.
Neurologic symptoms: Headache, no altered level of consciousness.
PHYSICAL EXAM:
VS: T 37C, HR 52, BP 111/62, R 18, 99% RA
General: Alert , no acute distress
Skin: Warm. dry. intact.
Head: Mild underlying cranial depression from previous craniotomy without noted swelling, tenderness, crepitus or bogginess. atraumatic.
Neck: Supple. trachea midline. No cervical tenderness or step-offs noted.
Eye: Pupils are equal, round and reactive to light. extraocular movements are intact. no discharge.
Ears, nose, mouth and throat: Tympanic membranes clear. Oral mucosa moist. No pharyngeal erythema or exudate.
Cardiovascular: Bradycardia with regular rhythm. No murmur. No gallop. Normal peripheral perfusion.
Respiratory: Lungs are clear to auscultation. respirations are non-labored. breath sounds are equal. Symmetrical chest wall expansion.
Gastrointestinal: Soft. Nontender. Non distended. Normal bowel sounds. No organomegaly.
Back: Nontender. Normal range of motion.
Musculoskeletal: Normal ROM
Neurological: Alert. No focal neurological deficit observed. CN II-XII intact. normal sensory observed. normal motor observed. normal speech observed. developmentally normal. normal gait.
EKG was performed, showing sinus bradycardia with 1st degree AV Block, and normal QRS duration. Received NS bolus and Tylenol which improved symptoms. Able to tolerate PO well and orthostatic vital signs were normal.
CBC showed WBC 12, Hgb 14, HCT 41, Plt 233. CMP showed Sodium 143, Potassium 3.9, Glucose 74, Calcium 8.5 and otherwise normal. TSH and Free T4 normal. UDS was positive for marijuana, but otherwise negative.
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We might want to explore the maternal concern about child not wanting to eat or drink very much recently. Any weight loss? Body image distortion?
Interesting case! While I agree in most scenarios first degree AV block is usually asymptomatic and found incidentally, my understanding is that since this child had a syncopal episode and found to have 1st degree AV block it could be a high grade block which would be a candidate for a pacemaker so my practice for this specific scenario would be to consult cardiology in the ED rather than the usual this is “incidental and you can follow up with cardiology as an outpatient” advice. Does anyone else have any thoughts?