KELLY WEBER, 15, arrives in your ED early one Saturday morning, accompanied by her mother. Half an hour ago, she began to feel light-headed and dizzy. Losing consciousness for about 30 seconds, she fell and hit her head on a coffee table. She was alert when she regained consciousness, and now says she feels fine. Kelly's mother is concerned because in the last month, Kelly has fainted twice at school, once during gym class, but recovered quickly after resting and drinking fluids.
What's the situation?
Kelly is alert, oriented, and in no appar- ent distress. You observe a small laceration and contusion on her forehead. Her vital signs are: BP, 108/68; pulse, 76; respirations, 22; temperature, 98.9 deg F (37.2 deg C); and Spo^sub 2^, 99% on room air. A fingerstick glucose reading is 108 mg/dl. Kelly has no history of seizures, migraines, diabetes, or congenital heart disease. She denies drug or alcohol use and takes no medications. Her menses began 3 days ago.
Kelly's mother denies that Kelly had cyanosis, tonicclonic movements, or urinary incontinence during the episode. She's of normal weight with no history of an eating disorder.
What's your assessment?
You suspect that Kelly experienced a vasovagal syncope episode, also known as fainting. When a person sits or stands, blood pools in the legs. Heart rate and vasoconstriction should push blood back to the heart, but in vasovagal syncope, the heart rate slows and vessels dilate instead, causing hypotension and cerebral hypoperfusion. The person may fall, but usually regains consciousness immediately after becoming recumbent.
Syncope can occur with or without a prodrome that may last for seconds to minutes; symptoms may include nausea, light-headedness, and dizziness.
Syncope can result from disorders of vascular tone or blood volume, cardiovascular disorders (including arrhythmias), cerebrovascular disease, or metabolic or psychogenic causes. In children and adolescents, syncope is most commonly vagally mediated.
What must you do immediately?
Listen to Kelly's heart for at least 1 full minute, noting the rate, rhythm, and presence of any murmurs. Obtain a 12-lead ECG, noting any rhythm disturbances, conduction abnormalities, or QT-interval prolongation. Measure Kelly's BP and pulse again in the lying, sitting, and standing positions, to determine whether she has orthostatic hypotension. Perform a neurologic assessment.
Obtain blood samples for complete blood cell count (to detect anemia) and chemistry profile (to reveal hypoglycemia or electrolyte imbalances), as ordered. Clean and dress Kelly's head wound.
What should be done later?
Kelly's vital signs and diagnostic tests are normal, so she'll be discharged from the ED. Because she's fainted twice before, including during physical activity, she'll need further diagnostic tests to determine the cause of her syncope. These tests might include a tilt-table test, an electroencephalogram, imaging studies of the brain and heart, or a 24-hour cardiac event recorder. Tell her not to participate in gym class until she sees her primary care provider for evaluation.
If Kelly has vasovagal syncope, her health care provider will recommend that she avoid dehydration by increasing her fluid and sodium intake and avoiding beverages that contain caffeine. She should eat small, frequent meals. If these measures aren't effective alone, she may need medications such as fludrocortisone, which causes sodium retention and helps prevent dehydration and hypotension. Beta-blockers such as atenolol also may be ordered to prevent large variations in heart rate.
BY ELLEN M. CHIOCCA, ANC, CPNP, MSN
Assistant Professor of Clinical Nursing * Coordinator, Pediatric Nurse Practitioner Program * Loyola University Chicago - Chicago, Ill.
Copyright Springhouse Corporation Jul 2003
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