Syncope in the Pediatric Emergency Department
With approval of the Institutional Review Board of Children's Healthcare of Atlanta (GA), we reviewed the electronic medical record of the two primary EDs (Children's Healthcare of Atlanta at Egleston and Scottish Rite) of our large pediatric tertiary care health care system from May 1, 2009 through February 28, 2013. Inclusion criteria were age eighteen years or younger with a chief complaint of syncope or near syncope (ICD-9 codes 780.2 and 780.4).
Data were collected on each patient by an experienced and trained abstractor (D.A.H.) using a standard software application, including demographics, the date of service, length of time spent in the ED, the time until the next ED visit, the chief complaint, a history of present illness, the ED diagnosis(es), the disposition from the ED, and the final hospital diagnosis(es) if admitted. ED diagnoses included ECG interpretations by the attending emergency physicians with review by a pediatric cardiologist within 24 hours. Final diagnoses were extracted from the attending of record documentation and listed in accordance with International Classification of Diseases, Ninth edition, by medical coders. Patients with a known history of structural, acquired, or electrical heart disease were not considered to represent new cases of cardiac syncope.
For those with a potentially new case of cardiac syncope, outpatient charts were also reviewed where follow-up was performed. Finally, the ED and inpatient (where applicable) records of 100 controls from those diagnosed with noncardiac syncope were reviewed to evaluate the sensitivity and specificity of the historical features. The initial chart review was performed by one reviewer (D.H.), with an additional reviewer involved in the categorization of each patient with a cardiac diagnosis with no discrepancies.
Our primary outcome of interest was an ED presentation of syncope in the patient with a new cardiac diagnosis. Our primary exposure variables were the historical features of presentation including exercise-related syncope with or without chest pain, absence of a prodrome, and palpitations associated with syncope. Because the utility of ECGs in the evaluation of syncope has been reported in the past, we sought to describe previously unreported historical features that might help predict a cardiac cause of syncope in ED presentations.
Data were summarized using mean (SD) and median (range) for continuous variables, and n (%) for categorical variables. After the descriptive analysis was completed, sensitivity and specificity, as well as positive and negative predictive values for historical features of syncope, were calculated using ED cases of syncope with a newly diagnosed cardiac etiology and 100 randomly selected patients from the same ED population with no cardiac etiology of their syncope. For all variables, we have reported 95% confidence intervals. We performed data analysis using Statistical Analysis Software (version 9.3; SAS Institute Inc., Cary, NC).
Materials and Methods
Data Source
With approval of the Institutional Review Board of Children's Healthcare of Atlanta (GA), we reviewed the electronic medical record of the two primary EDs (Children's Healthcare of Atlanta at Egleston and Scottish Rite) of our large pediatric tertiary care health care system from May 1, 2009 through February 28, 2013. Inclusion criteria were age eighteen years or younger with a chief complaint of syncope or near syncope (ICD-9 codes 780.2 and 780.4).
Data were collected on each patient by an experienced and trained abstractor (D.A.H.) using a standard software application, including demographics, the date of service, length of time spent in the ED, the time until the next ED visit, the chief complaint, a history of present illness, the ED diagnosis(es), the disposition from the ED, and the final hospital diagnosis(es) if admitted. ED diagnoses included ECG interpretations by the attending emergency physicians with review by a pediatric cardiologist within 24 hours. Final diagnoses were extracted from the attending of record documentation and listed in accordance with International Classification of Diseases, Ninth edition, by medical coders. Patients with a known history of structural, acquired, or electrical heart disease were not considered to represent new cases of cardiac syncope.
For those with a potentially new case of cardiac syncope, outpatient charts were also reviewed where follow-up was performed. Finally, the ED and inpatient (where applicable) records of 100 controls from those diagnosed with noncardiac syncope were reviewed to evaluate the sensitivity and specificity of the historical features. The initial chart review was performed by one reviewer (D.H.), with an additional reviewer involved in the categorization of each patient with a cardiac diagnosis with no discrepancies.
Outcomes and Variables of Interest
Our primary outcome of interest was an ED presentation of syncope in the patient with a new cardiac diagnosis. Our primary exposure variables were the historical features of presentation including exercise-related syncope with or without chest pain, absence of a prodrome, and palpitations associated with syncope. Because the utility of ECGs in the evaluation of syncope has been reported in the past, we sought to describe previously unreported historical features that might help predict a cardiac cause of syncope in ED presentations.
Statistical Analysis
Data were summarized using mean (SD) and median (range) for continuous variables, and n (%) for categorical variables. After the descriptive analysis was completed, sensitivity and specificity, as well as positive and negative predictive values for historical features of syncope, were calculated using ED cases of syncope with a newly diagnosed cardiac etiology and 100 randomly selected patients from the same ED population with no cardiac etiology of their syncope. For all variables, we have reported 95% confidence intervals. We performed data analysis using Statistical Analysis Software (version 9.3; SAS Institute Inc., Cary, NC).
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