A child who had a syncopal event can present a challenging disposition decision. When the cause of syncope is not readily apparent from the emergency department evaluation, multiple additional tests are frequently performed but rarely provide further diagnostic information. 31 Unfortunately, few studies have examined the most effective evaluation in the emergency department and the hospital.

Obviously, any child with a dysrhythmia documented by prehospital providers or on the ECG in the emergency department must be admitted. Children who have any of the risk factors in Table 127-2 should also be admitted in consultation with a pediatric cardiologist. Patients with a normal ECG but a history suspicious for an dysrhythmia are candidates for outpatient ambulatory cardiac monitoring.14 Identified causes of syncope should be treated as appropriate in the emergency department and admission to the hospital should be directed by the need for further evaluation or therapy. All children admitted for a syncope evaluation should be placed on a cardiorespiratory monitor in the hospital.

If, after an appropriately thorough history, physical, and laboratory evaluation, a clear precipitating cause for the syncope cannot be identified in the emergency department, the child may be discharged to home with close follow-up by the child's primary physician or a cardiologist. Because NMS accounts for up to 50 percent of the cases of syncope in children, most pediatric patients without cardiac risk factors or exercise-induced symptoms may be safely evaluated as outpatients. ™3132 Many of these children will have addition tests as outpatients, including portable rhythm monitoring, tilt-table testing, and stress testing, although the cost effectiveness of this approach remains in doubt.31

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