School picture day is often dreaded by children and their parents. Although finding the perfect outfit and keeping it clean, making sure remnants of breakfast aren’t present in the child’s teeth, and getting their hairstyle just right are typical stressors surrounding picture day, most parents do not think about their young student having a potential medical emergency just hours before saying “cheese.”

A 6-year-old girl presented to the emergency department a few hours after a brief syncopal episode. As the patient’s mother was curling her daughter’s hair in preparation for picture day, she noticed that her daughter was becoming restless and that her body began to sway. When describing the incident, the mother said, “I just thought she was becoming restless because she didn’t want her hair curled.”

The mom noticed something was wrong when her little girl’s head fell backward and her body went limp. The mother was able to cradle her daughter’s body to protect it from hitting any of the porcelain fixtures in the bathroom, but once the patient’s body was laid on the bathroom floor, the mom noticed a brief twitching of her upper extremities that lasted for a few seconds. After being unresponsive for approximately 30 seconds, the patient returned to her baseline mental status and went to school.

Understanding Syncope

Syncope is defined as a sudden, brief loss of consciousness associated with a loss of postural tone from which recovery is spontaneous. Syncopal episodes account for about three to five percent of emergency department visits and one to six percent of hospital admissions. The most common causes of syncope are “unknown” (34–36 percent), vasovagal (18–21 percent), and cardiac (9.5–18 percent).¹

All patients who present to the emergency department after a syncopal episode should have a thorough history taken, a physical exam, and an ECG.¹ Based on the patient’s age, comorbidities, history, and symptoms, a more thorough workup can be carried out. When interpreting the patient’s ECG, be mindful and document the presence or lack of conduction and interval abnormalities, ischemia, arrhythmias, delta waves to suggest Wolff-Parkinson-White, Brugada sign, and evidence of hypertrophic obstructive cardiomyopathy (HOCM).¹ If the patient’s history, physical exam, ECG, and other testing indicate the patient is low risk, most patients in this subgroup will be labeled as having experienced neurocardiogenic syncope or vasovagal syncope. In these cases, obtaining a pertinent history with directed questions regarding the events immediately preceding the syncopal episode is critical.