13 year old female CC: Syncope

EMS is called to a local hardware store for a 13 year old female with a possible seizure.

On arrival the patient is found sitting outside at a picnic table. Her mother and father are both present. The ambient temperature is hot and humid.

The patient's skin is very warm and moist but chalky. Her cheeks are pink which may be attributable to sunburn.

The patient's mother explains that the patient's sister had fallen off her bike and skinned her knee. The patient looked at the wound and fainted. She has fainted at the sight of blood before.

Neither the mother nor the father are interested in having their daughter transported to the hospital. A third party contacted 9-1-1.

They do, however, consent to an exam by EMS.

The patient is awake, alert, conversant, and oriented to person, place time and event.

Speach is clear and appropriate.

Equal smile, no arm drift, equal grip strengh, no pass pointing.

  • Past medical history: Healthy
  • Medications: None.

When questioned about family history (specifically about any history of a relative passing away unexpectedly from sudden cardiac arrest) the patient's father states that his brother died of a cardiac arrest at the age of 16.

When asked for specifics he states, "Some kind of seizure disorder. I was young."

Vital signs are assessed.

  • RR: 20
  • Pulse: 84
  • BP: 114/59
  • SpO2: 99 on RA
  • Temp: 99.1

The cardiac monitor is attached.

A 12-lead ECG is obtained.

The patient's skin color is now improved and she states she feels "fine".

Questions:

1.) Why did the paramedics ask questions about the family history?

2.) Why did the paramedics perform a 12-lead ECG?

3.) Do you see anything that would suggest this patient is at-risk of anything life-threatening?

4.) Is it okay for the parents to refuse transport to the emergency department?

See also:

13 year old female CC: Syncope – Discussion

34 Comments

  • Mike from Mass says:

    Diligent care! Great case.

    It seems the medics identified a case of long QT syndrome! Although parents clearly have the right to refuse for their minor child, I’m confident that the paramedics who were diligent enough to capture a 12-lead ECG on a potential pediatric patient refusal would exhaust all means of convincing the parents of the need for specialist evaluation.

  • Thanks for chiming in, Mike! I'm hoping we can have a meaningful discussion about this case. You are wise to consider long QT syndrome. But the QTc is only 438 ms. Is that really prolonged? Why would a prolonged QT be significant?

  • Jeremy from NH says:

    V1 Looks like the QTc is more like .5. Which leads do the monitors measure or do they do and average?

  • I'm not sure exactly how the computer measures the QT/QTc. However, if you look at the second cardiac cycle in lead V1 you can see that the QT is just less than 400 ms and the computer measures it at 382 ms (18 ms short of 400 ms). Seems legit to me! How did you arrive at 500 ms?

  • Benjamin says:

    Long QT syndrome can present as syncope with a triggering event, i.e. fainting when seeing blood. It was important to ask about a family history of sudden cardiac arrest also because that is another linking clue of possible long QT syndrome. Like Mike from MA said, the parents definitely have a right to refuse treatment and transport, however i'm sure the medics in the case were competent enough to not let that happen.

  • Dodge says:

    Eliciting a family history about a normally healthy child could reveal a serious family history and in this case there is a history of early death in this case the child’s father’s brother died at 16, this to me is a significant finding in itself. A 12 lead e.c.g. would rule out or in the presence of a significant arrhythmia such as sic sinus.
     I thought there was a prolonged QT interval as well and if this was a significant finding it may lead to VT or torsades and this could be the reason for the father’s brother’s condition as sick sinus can cause the appearance of seizure like activity.
    While it is the parents right to refuse I would do everything in my power to convince them that the child really dose need to be fully assessed to exclude any major electroconduction deficits, that could cause a disastrous outcome to the child’s safety  
    Hope this suffices but having no 12 lead experience I am flying a little bit blind here

  • Benjamin – I share all of your concerns about the family history. But are there abnormal findings on the ECG? Does it show a prolonged QT/QTc?

  • Thanks for the comment, Dodge! One of the points that I'm trying to prove here is that our job, when done correctly, is difficult! I know a lot of paramedics who wouldn't have even bothered putting the patient on a monitor, let alone obtain a 12-lead ECG.

  • Neal says:

    I am enjoying reading this discussion about LQTS and some discussion about channelopathies. Sounds like the medics were diligent with their interview. There is a form of concealed long qt syndrome that exists and is demonstrated with a paradoxical lengthening of the qt interval as heart rates increase with catecholamine influence. Looking at the 12 lead the patients heart rate does not appear to be very brisk. Given family history I think a cardiac consult would be advised.

  • Dodge says:

    I hear ya tom our service dose not utilise 12 lead as yet but it is coming except for us volunteers we wont be allowed but i do always check ecg for any call that involves LOC for any cause it just makes sense to

  • Ryan says:

    1. Because you should
    2. See #1
    3. No, and it makes me first think that it could have been a simple vaso-vagal, though, given the heat and current status regardless of how the child turns around, I will strongly suggest why the child should go, and it is definitely suggested.
    4. While it may be within their right to refuse, I would explain my discomfort in allowing this. Plus, was there any actual seizure activity witnessed? Trauma? Anything else?

  • Good point, Ryan! No, there was no seizure activity of any kind (not even anoxic seizure at the time of the fainting), no post-ictal state, she did not hit her head, and the head is atraumatic. I share your discomfort (I always feel better when patients are transported) but when the parents ask whether or not the ECG shows anything concerning how should we respond? Do you see anything abnormal? Can we rule out significant life-threatening causes of syncope with a 12-lead ECG? Or if not completely rule-out, at least check for them? This case reminds me a little bit of the recent case by Burned-Out Medic. What's the most difficult ECG-diagnosis in all of medicine?

  • Brandon O says:

    Tom: "Normal ECG"!
     
    The ECG is unexciting for me, but I'm not great with long QT. The history hits on a couple bingos, possible family history and now a hx of syncope. To me that suggests the kid should definitely be seen by a cardiologist. Is it urgent? Ehh… the syncope happened now, which may suggest a period of increased risk. If you ask if I think they're in real danger, I'd say no. But that applies to a lot of the people we transport for eval, and in this case the "whoopsy" would be a sudden pediatric arrest. A better understanding of empirical LQT risk would be helpful here.

  • Troy says:

    You say prolonged QT, I say LGL.

    Short PRI with a wide (>.09) QRS leads me more towards and accessory pathway. Would explain the siezure like activity especially when the heart is going 300 with no regulator

  • Troy says:

    Plus it has a high genetic factor just like WPW.

  • Christopher says:

    I first looked for LQT, but with a normal QTc I'm ok with it. There is a U-wave visible in the right precordials which some folks may have used in their QT calculation. The PRi is slightly shortened, and as Troy pointed out the QRSd is slightly prolonged for a pediatric patient. I don't have Chou's with me now or in the field to check the reference durations for a 13 year old female, so I have to fall back on my rules and >0.08s is "wide".
    However, that being said, the history points to a vaso-vagal reaction to the sight of blood and it may be fairly difficult to convince the parents otherwise. We should try our best to encourage transport due to the potential for serious adverse effects. In all likelihood the parents in this case are going to refuse, so I'd get a good refusal done and supply a copy of the 12-Lead to take with them to their pediatrician.
    Good case.

  • David Baumrind says:

    well, i am not sure what it all means, but in the rhythm strip, the P waves are somewhat tall and peaked, as in RAE… also, there is right axis deviation with some possible early transition, wondering if there is some persistent right sided dominance still going on.. also noticed the notching of the s waves, with slightly prolonged conduction during second half of QRS.

  • ToddB says:

    I would say there is enough evidence to at least educate the parents about the possibilities of LQT and HCM.  There is some evidence of hypertrophy on the ECG in my opinion, and when we consider that the leading cause of death in young athletic folks is HCM (and that LQT is third) it only makes sense to educate the parents about the possibilities.  The family hx supports this as well.  If they refuse after understanding the possible risks so be it.  Give them the 12 lead and suggest they see the childs MD.

  • Troy says:

    HCM? Hypertrophic Cardiomyopathy?

  • ToddB says:

    Troy…yes sorry.

  • Richard says:

    In LGL the QRS complex is narrow as the ventricles are stimulated in the Bundle of His so it cannot be LGL as suggested earlier.

    There are R waves in V1-3 which is not usual

    I don’t like the shape of the ST-T complex but cannot explain it.

    As for the father whose brother died suddenly aged 16 I would be concerned about his refusal to let his daughter attend ER. I would seriously consider informing social services.

    Very pointed P waves: consider pulmonary hypertension causing P pulmonale and r waves V1-v3

  • 1. the crew was thorough.
    2. 12-lead is mandatory for syncope.
    3. other than rightward axis, i don't see a lot.
    4. probably OK (as in outcome) if they really, really refuse. there's a proximate and reasonable explanation for the event. but i was not there.

  • Ken Grauer says:

    Interesting case.  ALL intervals are normal to my reading for this pediatric patient.  The PR will normally be shorter in children (smaller hearts) – though for a 13-year old the PR range is not that much different than for an adult.  The same for the QRS – which I interpret as normal for this 13-year old. The computer does its best to calculate the QT from taking the longest interval which "it" sees.  By my method (page 29F below) – I get just about the same 0.44 second as does the computer for the QTc – which is upper normal, but not nearly long enough to raise concerns about long QT syndrome (I'd look more for a QT of 480-500 before really getting worried … ).  That said – the fact that EMS is ON THE SCENE – and they then have a minor who fainted (even though it sounds vasovagal) with a very positive family history (a sudden death at age 16) – really puts them in a bind.  My suggestion – CALL their medical director (since it sounds like they have a moment to do so, as the child is stable).  So if I was that medical director – I'd also feel in a bind – but I suspect I would have the child brought in to be seen in the ED . . . . (which may lead for a messy situation, possibly requiring legal action if the parents still refused . . . .).  All of this said – if I was in my family practice, with a better handle for knowing the child and the family – would be easier to negotiate some solution (the child DOES need to be seen by cardiology given a history of fainting and a sudden death at age 16 in the family) – but not necessarily immediately . .. . which is VERY DIFFERENT than being called as an EMS Unit on the scene to see a child who fainted . . .   Excellent case for discussion.
    Click HERE for a mini-didactic on the QT interval.  Page 28 shows the basics (and the "quick way") to calculate whether the QT is normal or long – and for those who want more, page 29F has my favorite shortcut to get closer.

  • David Lee says:

    I am just an echovascular tech, however I think with the high voltage of the EKG and the family hx that this is most likely a case of hypotrophic cardiomyopathy with a LVOT obstruction. The excitnent of seeing the blood increased the bp witch increased the velocity across the LVOT causing SAM of the MV causing the syncopale episode.

  • Mufaddal says:

    RIght axis deviation on cardiac monitor would have prompted a 12 lead ECG, which shows normal intervals and right/septal hypertrophy. HCM should be the first differential to be ruled out with an ECHO and hence patient should be transported to the ED.

  • Christopher says:

    Found this interesting study thanks to a newer blog, EM Literature of Note, which points out that  many patients with Brugada do not have ECG changes!

    OBJECTIVES: The objective of this study was to determine the prevalence of conventional risk factors in sudden arrhythmic death syndrome (SADS) probands with Brugada syndrome (BrS).

    BACKGROUND: Patients with BrS and previous aborted sudden cardiac death (SCD) are at high risk of recurrent events. Other universally accepted clinical features associated with higher risk include unheralded syncope and the presence of a spontaneous type 1 electrocardiogram (ECG).

    METHODS: We analyzed reported symptoms and reviewed ECGs from SADS probands with familial diagnoses of BrS, established by cardiological evaluation, including ECG, 2-dimensional echocardiography, Holter monitoring, exercise tolerance testing, and ajmaline provocation. These cases underwent familial evaluation between 2003 and 2010.

    RESULTS: A total of 49 consecutive families with a confirmed SADS death and a diagnosis of BrS were evaluated, comprising assessment of 202 family members in total. One family had 2 members with SADS, resulting in a total of 50 probands included. Mean age of death of probands was 29.1 ± 10.6 years, with 41 males (82%) (p < 0.05). Antemortem ECGs were available for 5 SADS probands, 1 of which demonstrated a spontaneous type 1 pattern. In 45 probands, symptoms before death were reported reliably by family members. Of these, 9 (20%) had experienced at least 1 syncopal episode before the fatal event. Importantly, 68% of probands would not have fulfilled any current criteria for consideration of implantable cardioverter-defibrillator.

    CONCLUSIONS: The "low-risk" asymptomatic BrS group comprises the majority of SCD in this cohort. Current risk stratification would appear to be inadequate, and new markers of risk are vital.

  • Ian says:

    Hi Tom,
    If we listen to the child's heart, are there any murmurs? Is there an increased jugular venous collumn? Clubbing of the fingers, hepatomegaly, edema?
    A history of previous syncopal episodes with the right axis deviation point to the possiblity of congenital heart disease. 

  • Will says:

    Alhough the ecg appears relatively normal, I am not concerned with those strips. What I am concerned about is what I didn't see on the ECG and that would be what was it like when the syncopal episode occurred.  Working in telemetry I get to see patients go in and out of various blocks including high degree blocks just to resume a NSR a few moments later.  So could the patient have had a episode of Mobitz II or Third degree with ventricular standstill inducing the syncope? Although the likely story is the child freaked when they saw blood, while the patient is not currently having the episode we really shouldn't try to rule that out just because everything appears normal now.
    The QT interval appears to be .38-.40 which isn't to me an eye catcher initially. The right axis could mean alot or nothing at all. I may have asked what activities is the child normally involved in. People who play high impact sports such as football or martial arts can develop accessory pathways such as WPW. Although there is not a defined delta wave, is that axis deviation normal for that patient?

  • RhiB says:

    Not sure that I see the prolonged QT syndrome. There is some unusual morphology in the T waves with a some slurring but nothing too eye catching. What about LVH as the QRS complex in aVL is over 11 mm in amplitude and almost exclusively negative in deviation wich would be suggestive of hypertrophic cardiomyopathy and given the patient familial history could put the pt at risk for sudden cardiac arrest.

  • Steven Carter says:

    I don't know much about LGL, Tom but with the syncope and familial history of SCD I would be suspicious of Brugada Syndrome.  There are no findings here to suggest Brugada, however her present skin signs are improving to asymptomatic.  Although its more common in makes, she should be evaluated.

  • RonG says:

    I favor the finding of LGL.  This pre-excitation condition affirms the use of an accessory pathway… which we know can lead to all sorts of funky dysrhythmias.  If one looks at leads V1-3, one can see some extra P-waves (must be a short run of 2:1 conduction?).  Of course the parents can refuse treatment.  Maybe they're alert to the costs of pre-hospital healthcare and want to avoid the $600-1200 ambulance bill that comes with transport.  The parents need to be told that their child's condition warrants further assessment by a cardiologist.

  • porrohman says:

    The long QTc and I don't like that zig zag in the QRS. This is not a ptaient I would easily and willingly sign off'

  • Kyle says:

    Lead 1 is negatively deflected.  that would cause me t do a 12 lead even if I wasn't going to by default.  After I checked lead placement.  

  • techy says:

    Hi folks interesting case enjoyed reading your comments. Here in the UK a child of 13 has the ability to consent on treatments/transport. I.e as long as they can understand the clinical need for treatment or observation they can accept even if the parents refuse. If the kid was unable to consent the only way and the child’s parents refused treatment the only way you could overrule them would be if life threatening interventions were required. Consent with children can be a grey area and I expect is different in all countries but they could of leaned more on the child for reasons for transport maybe???

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