Breath-Holding Spells Are More Complicated than Imagined

It never ceases to amaze me how nothing is ever as simple as it seems. Breath-holding spells are just the latest of the simple and common medical conditions that turn out to be much more complex than ever imagined.It all started during a recent shift in the pediatric emergency department with a toddler who presented after a breath-holding episode. He fell after losing his balance on a trampoline.It started as a classic pallid breath-holding spell that then manifested as crying out, stopping breathing, and rapidly losing consciousness. He then had a CNS anoxic event. The unconscious child clenched his fists and arched his back into opisthotonos posturing. The whole event played out over 30 to 45 seconds, and he was pale afterwards.This is where the story became more interesting. It appeared he had had a simple breath-holding episode, but he was actually in a subset of children who have a more severe cardioinhibitory presentation of this syndrome. An ambulatory cardiac monitoring device had previously documented that he rapidly proceeded through vasovagal-induced bradycardia that progressed to asystole.He was being treated with a mineralocorticoid, fludrocortisone. The patient's cardiologist said he may ultimately need a pacemaker and his medical record listed cardioinhibitory malignant vasovagal syndrome. Even though this nomenclature is not widely used, it adequately defines what is going on with this patient.I researched this patient's condition and began to see breath-holdi...
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