Syncope or Presyncope with Suspected Cardiac Cause - Paediatric CPC

For clinical advice, please telephone the relevant specialty service.

Women's and Children's Health Network

• Women’s and Children’s Hospital (08) 8161 7000

Inclusions

• syncope/presyncope with suspected cardiac origin:
  • brady/tachyarrhythmia
  • abnormal electrocardiogram (ECG) suggestive of arrhythmia, e.g. long QT syndrome (LQTS), Wolff-Parkinson-White (WPW) syndrome, Brugada
  • known underlying arrhythmia – long QT syndrome, Brugada syndrome, Wolff-Parkinson-White syndrome
  • known or suspected structural abnormalities e.g. aortic stenosis, hypertrophic cardiomyopathy

Exclusions

• all other suspected causes (non-cardiac) of syncope/presyncope, including presyncope without evidence of arrhythmia - refer to Paediatric Medicine Syncope and Presyncope CPC

Triage categories

Category 1 (appointment clinically indicated within 30 days)

• syncope during exercise
• syncope with documented non-sustained arrythmia
• syncope with known or suspected structural cardiac anomalies

Category 2 (appointment clinically indicated within 90 days)

• recurrent syncope suspicious of arrhythmia

Category 3 (appointment clinically indicated within 365 days)

• recurrent syncope likely vasovagal

Essential referral information

Completion required before first appointment to ensure patients are ready for care. Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.

• clinical history including:
  • presenting symptoms/features including:
    • associated chest pain or palpitations
    • characteristics of syncopal episode including onset, duration, recovery post
    • associated cyanosis or pallor
    • frequency of events/episodes/witnessed/unwitnessed
    • previous/current management
  • exercise tolerance
  • past medical history, please provide any relevant features as relating to triage categories
  • family history of genetic cardiac arrhythmia/s, or sudden unexplained death in children or young adult/s
  • medications and allergies
• physical examination findings
  • blood pressure, including trends, postural blood pressure
  • heart rate (HR)
  • cardiac exam findings

Additional information to assist triage categorisation

• quality of life concerns including missed work/school/extracurricular activities as a result
• electrocardiogram (ECG)
• bloods, e.g. haemoglobin (Hb), iron levels
• relevant diagnostic/imaging reports, including location of company and accession number
• previous discharge letters and/or correspondence related to cardiac presentations

Clinical management advice

Taking an accurate history of the syncopal episode is important in being able to identify red flags, to suggest a cardiac cause of syncope, e.g. syncope while running compared to syncope after stopping running.

Management for Postural Orthostatic Tachycardia Syndrome (POTS)

Postural Orthostatic Tachycardia Syndrome (POTS) is common in teenagers, and can usually be managed conservatively without medications. Symptoms will improve over time in most teenagers.

• Trial of conservative management would/should include:
  • water intake - 2 to 3L per day, taking 200mls every couple of hours
  • increased salt intake - add to diet or salt tablets
  • leg muscle strengthening exercises
  • use of compression stockings
  • avoid hot steamy showers/saunas
  • avoid prolonged standing in one position
  • stand up slowly, move legs when standing for longer periods
• To manage symptoms:
  • lie down immediately when dizzy, then sit up slowly
  • drink water

Clinical resources

• Royal Children’s Hospital Melbourne Clinical Practice Guideline - Syncope
• Royal Children’s Hospital Melbourne Clinical Practice Guideline - Basic Paediatric ECG Interpretation

Reason for request

• to establish a diagnosis
• for treatment or intervention
• for advice and management
• for specialist to take over management
• for a specified test/investigation the General Practitioner cannot order
• for other reason (e.g. rapidly accelerating disease progression)
• transfer of care from another tertiary service
• clinical judgement indicates a referral for specialist review is necessary.

Patient demographic details

• full name, including aliases
• date of birth
• residential and postal address
• telephone contact number/s – home, mobile and alternative
• Medicare number, where eligible
• name of the parent or caregiver, if appropriate
• preferred language and interpreter requirements
• identifies as Aboriginal and/or Torres Strait Islander

Clinical modifiers

• impact on employment
• impact on education
• impact on home
• impact on activities of daily living
• impact on ability to care for others
• impact on personal frailty or safety
• identifies as Aboriginal and/or Torres Strait Islander

Other relevant information

• Willingness to have surgery, where surgery is a likely intervention.
• Choice to be treated as a public or private patient.
• Compensable status, e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.
• Relevant social history, including identifying if you feel your patient is from a vulnerable population, under guardianship/out-of-home care arrangements and/or requires a third party to receive correspondence on their behalf.
• Triage of a specialist outpatient referral is based on clinical decision making to allocate an appropriate urgency categorisation.
  
• Where appropriate and where available, the referral may be streamed to an associated public allied health and/or nursing service. Access to some specific services may include initial assessment and management by associated public allied health and/or nursing, which may either facilitate or negate the need to see the public medical specialist.
• A change in patient circumstance (such as condition deteriorating or pregnancy) may affect the urgency categorisation and should be communicated as soon as possible.
• All new referrals will be triaged by a consultant and appointment times scheduled according to clinical urgency.

Adolescents transitioning from paediatric to adult specialist services require a formal handover from paediatric specialist clinician to adult specialist clinician as well as a formal referral from the referring specialist to ensure initial transfer of care is completed.

The role of the referring clinician (e.g. General Practitioner, Nurse Practitioner) in this process is to provide support to patients as part of holistic care. All ongoing referrals to specialists can subsequently be provided by the referring clinician once the transfer of care has occurred.