The most crucial step in evaluating a child with a syncopal or near death event is a careful medical history. Interview any family members, friends, or witnesses who were with the child just prior to the event. The events leading up to the incident should be described in detail, as should any apparent change in the child's behavior or symptoms. Pay particular attention to details such as the intake of medications, drugs, fluids, and food. Note the position the child was in when syncope occurred, because recumbent positioning is less consistent with NMS or other forms of vascular syncope. A history of syncope during exertion or exercise increases the likelihood of the more serious etiologies. The prodromal symptoms will often aide in identifying the cause of the event. The sequence and timing of motor movements, level of consciousness, and postural positioning will help to differentiate primary seizures from NMS or other true causes of syncope. A history of previous syncopal events should be sought. Any known medical problems should be considered, especially known cardiac diseases, diabetes, seizures, medication or drug use, or psychiatric or psychological problems. Ask about a family history of structural cardiac disease, dysrhythmias, sudden death, migraines, or seizures. Statements by the witnesses that the patient appeared dead and required cardiopulmonary resuscitation (CPR) must be evaluated carefully. The duration of pulselessness and the degree of intervention required should be carefully recounted by the witnesses. Anytime that CPR has been performed, even if by an inexperienced layperson, the event should be considered a resuscitated sudden death and evaluated comprehensively.
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