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Pediatric Cardiology 101: Syncope, Chest Pain

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Keep your attention and teach ya some useful stuff ... IF IT WAS A TRUE OUT AND OUT FACE-PLANT (dirtintheteeth) WHILE EXERTING THEN. ... – PowerPoint PPT presentation

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Title: Pediatric Cardiology 101: Syncope, Chest Pain


1
Pediatric Cardiology 101 Syncope, Chest Pain
Murmurs
  • Karen Raines, MD
  • Associate Professor of Pediatrics
  • WFU School of Medicine
  • And
  • Whitewater Raft Guide
  • New Gauley Rivers, West Virginia

2
I have no conflicts of interest to disclose
3
Objectives
  • Keep your attention and teach ya some useful
    stuff
  • Review syncope in the ped pt including the when
    to worry and when not to worry types and their
    evaluation
  • Review chest pain in the ped pt ditto above
  • Quick review of the common normal murmurs found
    in children
  • Sneak in a few rafting videos!

4
SYNCOPE
5
Definitions
  • Syncope transient loss of consciousness
    muscle tone most often due to inadequate cerebral
    perfusion
  • Pre-syncope the feeling that one is about to
    pass out but no loss of consciousness
  • Sudden death fall down, but dont get up

6
How Common is It?
  • Probably more common than reported
  • Variable reports range from 12,000 ped ER visits
    to 47 of interviewed college students
  • Best estimate is about 15 of children will
    have syncope
  • Often a familial tendency towards syncope is
    discovered

7
Why So Much Angst?Fancy word for worry
  • Is syncope a harbinger of sudden death?
  • Well, it depends on the circumstances of the
    syncopal episode
  • Simple syncope is NOT associated with a higher
    incidence of sudden death

8
HOWEVER . . .
  • SYNCOPE DURING EXERTION MAY BE THE ONLY WARNING
    OF A LETHAL CONDITION

9
Categories of Syncope
  • Neurocardiogenic
  • Cardiac
  • Non-cardiac

10
Neurocardiogenic Syncope
  • Most common cause of syncope
  • Multiple names
  • Neurally-mediated syncope
  • Vasovagal syncope
  • Simple fainting
  • Disturbed autonomic control of HR BP in
    response to emotion, pain or postural change
    (Huh?!) whatdidshesay?!

11
The Physiology Part(But no biochemical flow
charts!!!)
  • Surveillance of blood pressure performed by
    multiple receptors
  • Baroreceptors
  • Carotid artery bifurcation (carotid sinus)
  • Aortic arch
  • Mechanoreceptors
  • Atria
  • Pulmonary artery
  • Left ventricle

12
More Physiology !
  • Afferent (input) signals from receptors are sent
    to medulla
  • Parasympathetic part
  • Nucleus ambiguus
  • Dorsal motor nucleus of the vagus
  • Sympathetic part
  • Costal ventromedial ventrolateral medulla

13
A Little More !
  • Two pronged output results
  • Sympathetic withdrawal
  • Vasodilatation
  • Decreased contractility
  • Parasympathetic output
  • Venodilation
  • Decreased heart rate

14
So What Makes Em Sink?
  • Appears to be due to excessive input from the
    cardiac mechanoreceptors
  • Stretch or distortion is detected, but its due
    to an empty stretching inward heart, not a full
    one!
  • Which triggers one last physiology slide and
    diagram !!!

15
What Reflex You May Ask?!?
Bezold-Jarisch
Reflex
16
(No Transcript)
17
Evaluation of the Sinker
  • History
  • Physical exam
  • EKG

18
History
  • Probably the single most important part of the
    evaluation
  • Careful, non-hurried non-leading questions
    detailing entire episode
  • Description of circumstances, prodrome, the
    actual faint and after-effects/appearance from
    patient and/or observers

19
Circumstances
  • Where did it happen
  • Time of day
  • ?meals, ?intake
  • Body position
  • Preceding activity
  • Any intercurrent illness

20
Prodrome
  • What was the first sensation?
  • Time betw 1st warning the faint?
  • Any visual changes?
  • Any auditory changes?
  • Any nausea, diaphoresis or pain?
  • Any palpitations preceding the event?
  • If so, temporal relationship to event

21
The Faint
  • Any injury?
  • Do they remember the fall?
  • How long unconscious?
  • Any tonic activity (vs T-C)?
  • Appearance during?
  • Color, diaphoretic?
  • Incontinence?

22
After the Faint
  • Whats the first thing they remember?
  • Any feelings of nausea, headache, chest
    sensations, confusion, fatigue
  • ?Get up too fast?
  • Skin color and ?diaphoretic
  • How long until totally back to normal

23
Typical Sinker Story
  • Pre-teen or teen, sitting or standing
  • Prodrome of hot feeling, nausea, racing heart,
    sweaty
  • Hearing often dims
  • Vision often grays out or tunnel vision
  • Falls to floor without serious injury
  • May have tonic activity

24
Typical Sinker Story
  • Awakens nearly immediately
  • Described as pale, clammy, pasty gray,
    diaphoretic
  • Often feels nauseated and fatigued for a while
    may not be back to normal for many hours
  • Recurs if helped up too quickly

25
History - Other Aspects
  • Voiding history at school
  • Prior medical history including cardiac history
    (duh)
  • Previous syncopal episodes
  • Medications
  • Illicit drugs, behaviors (privately, of course)
  • Family history

26
Family History
  • Sudden unexpected death
  • HCM, LQTS, arrhythmias, etc
  • Syncope
  • Seizures
  • Migraines

27
Physical Exam
  • Complete with special attention to
  • Cardiac exam
  • Neurologic exam

28
Cardiac Exam
  • Palpate
  • Displaced PMI - lift/heave
  • RV lift/heave
  • Thrills
  • Palpable S2
  • Murmurs of outflow obstruction
  • Single S2 indicative of pulm HTN

29
EKG
  • A must (in my opinion others)
  • WPW syndrome
  • Short PR with wide QRS (BBB)
  • Syncope can be from a-fib with rapid ventric
    response
  • Long QT Syndrome(s)
  • Conduction defects
  • Complete block, familial cond defects, etc
  • Ventricular hypertrophy

30
Further Evaluation or Not?
  • If history typical, physical and EKG both normal,
    then further testing /or referral not necessary
  • Explanation
  • Reassurance
  • No risk of SD, benign temporary
  • Start simple therapy

31
Lay Explanation
  • Basic explanation of reflexes
  • Immaturity /or exaggerated reflexes in
    pre-teens, teens
  • Involves brain, heart blood vessels
  • Stress benign nature
  • Stress no risk of sudden death
  • Stress self-limited time course

32
NMS Rx - 1st Step
  • Goal is to increase circulating volume
  • Increased fluid intake
  • Mention potential diuretic effect of caffeine
  • Use more salt or salt tablets
  • Stress importance of paying attention to the
    warning signs
  • Get your head down

33
NMS Rx - 2nd Step
  • Mineralocorticoid fludrocortisone (Florinef)
  • Dose range 0.1 mg qd or bid (max 0.4 mg/d)
  • Must still maintain good fluid intake
  • Warn about tight shoes!
  • Takes few days to week for full effect
  • Essentially, no side-effects
  • Usual treatment course 6-12 mo

34
NMS Rx - 3rd Step
  • Multiple other agents available
  • Beta-blockers
  • Alpha-agonists
  • Serotonin agonists

35
Cardiac Causes
  • Obstruction to flow
  • Myocardial dysfunction
  • Arrhythmias

36
Cardiac Causes
  • Obstruction to flow
  • Aortic or pulmonary stenosis
  • Hypertrophic cardiomyopathy
  • Primary pulmonary hypertension
  • Eisenmengers syndrome

37
Cardiac Causes
  • Myocardial dysfunction - primary
  • Dilated cardiomyopathy
  • Neuromuscular disorders
  • Duchenne, Becker, Myotonic, etc
  • Myocardial dysfunction - secondary
  • Inflammatory - myocarditis, Kawasaki
  • Ischemia - coronary abnormalities
  • Aneurysm/obstr, ALCA, aberrant coronary

38
Cardiac Causes
  • Arrhythmias (nl heart vs CHD pt)
  • Tachycardia
  • VT or SVT (espec WPW)
  • Channel-opathies
  • Long QT, Brugada, probably more
  • Conduction abnormalities
  • Sinus node dysfunction
  • AV block
  • Arrhythmogenic RV dysplasia

39
Non-Cardiac Causes
  • Seizure disorder
  • Often have aura, T-C activity and period of
    post-ictal confusion and lethargy
  • More likely to be confused with simple syncope if
    complex partial type
  • Convulsions occur before LOC
  • Usually warm flushed after (not pallid or
    diaphoretic)

40
Non-Cardiac Causes
  • Breath holding spells
  • Ages 6m-18m typical up to 6 yrs old
  • Precipitated by pain, anger, etc
  • Cry gt long expiration gt apnea gt LOC
  • Pallid form often with asystole
  • Often have tonic posturing
  • Cyanotic form is blue (duh!)
  • Resolves with LOC and breathing
  • Benign resolves by age 5-6 yo

41
Non-Cardiac Causes
  • Migraine (basilar artery migraine)
  • Typical presentation is headache aura, then LOC
    and awake w/ severe occipital HA
  • Some dont have headache
  • More in adolescent girls

42
Non-Cardiac Causes
  • Drugs
  • Espec illicit ones
  • Huffing volatile agents
  • Metabolic
  • Hypoglycemia VERY RARE (maybe never!) cause
    unless diabetic

43
Non-Cardiac Causes
  • Hyperventilation
  • Usually assoc w/ anxiety, c/o dyspnea, chest
    discomfort, dizzy paresthesias
  • More common in adolescents
  • Hypocapnia gt decr cerebral blood flow
  • Hysteria
  • Always audience present graceful swoon
  • LOC for long period

44
Non-Cardiac Causes - Situational Syncope
  • Cough syncope
  • More often in pt w/ lung disease
  • High thoracic press gt decr return
  • Swallow (deglutition) syncope
  • Rare in peds more in adults
  • Esoph receptors gt CN IX gt vagal output

45
Non-Cardiac Causes - Situational Syncope
  • Micturition syncope
  • Usually male before, during or after voiding
    (often fatigue, alcohol hx)
  • Unknown causes
  • Proposed due to combo of postural hypotension,
    visceral stretch receptors, vagal stim, etc
  • Benign usually an isolated episode

46
Non-Cardiac Causes - Situational Syncope
  • Hair-grooming / neck stretch syncope
  • Nearly always in adolescents
  • Possible mechanisms include trigeminal nerve
    stim, carotid sinus hypersensitivity,
    vertebrobasilar circulation changes
  • Benign

47
When To Worry
  • Circumstance
  • Syncope during exertion
  • Known cardiac patient
  • Malignant family history
  • Prodrome
  • Angina
  • True palpitations

48
When To Worry
  • The Faint
  • True sudden death (big duh!)
  • Prolonged LOC (/-)
  • Serious bodily injury during fall (/-)
  • After event
  • Tachy-arrhythmia present

49
When To Worry
  • Abnormal physical exam
  • Abnormal EKG

50
Syncope During Exertion
  • Careful history about details
  • IF IT WAS A TRUE OUT AND OUT FACE-PLANT
    (dirtintheteeth) WHILE EXERTING THEN . . . . .
  • Must exclude 3 potentially lethal conditions in
    ostensibly normal person

51
Must Exclude
  • Anomalous left coronary artery
  • Aberrant coronary artery
  • Hypertrophic cardiomyopathy

52
Anomalous Left Coronary Artery
  • Left coronary arises from pulm art
  • Problem is not blue blood perfusing the
    myocardium
  • Problem is run-off of blood bypassing the
    myocardial capillary bed and dumping into the low
    resistance pulm circulation
  • Age mode of presentation depend on collateral
    connections, flow, etc

53
Aberrant Coronary Artery
  • Coronaries arise from aorta, but a major branch
    courses BETWEEN the Ao and PA
  • Most common variant is LAD off the right
  • Exercise gt high cardiac output gt Ao PA dilated
    gt compresses coronary gt oops !

54
Hypertrophic Cardiomyopathy
  • Usually, physical exam and/or EKG are abnormal
  • May not have positive family history
  • Can be very subtle

55
CHEST PAIN
56
Chest Pain
  • Extremely common complaint, but I dont have any
    numbers
  • Typically in the pre-teen, young teen age
  • Probably all kids have some occasional pain, but
    not all of them complain
  • Often it has been going on for a while but not
    mentioned to parent

57
My Opinion
  • The media campaign to save adults from heart
    attacks has led to a paranoid generation of lay
    people and the medico-legal society we live in
    has created the problem of over-reaction (the
    CYA approach to medicine). Additionally the
    sensationalism of rare sudden deaths in athletes
    heightens the parental anxiety.

58
The Benign Story
  • Typical age is pre- to early adolescence
  • SHARP, RANDOM stabbing mid-sternal chest pain
  • Worse with breathing
  • May have recently started a new activity or had
    an injury
  • Sometimes mention a tender area on chest
  • Often a family history of heart problems

59
History Tid-bits
  • Establish that pain occurs sometimes at rest
  • Confirm aggravating factors movement, deep
    breaths, etc
  • Query about new activity (new bike, new exercise
    equipment, etc) or injury
  • Ask about attempted home treatments (antacid,
    analgesics how given)

60
Physical Exam Tid-bits
  • Obviously perform careful cardiac exam looking
    for cardiac enlargement, murmurs, single S2, etc
  • Assess for tender areas
  • Pressure on sternum
  • Side rib squeeze

61
Then Teach Em a Cool New Word !
62
Costochondritis
63
Explanation
  • I review basic thoracic cage anatomy
  • Breakdown word costochondritis into its separate
    parts (handout helpful)
  • Stress benign nature of real pain (not
    imaginary!)
  • Ibuprofen bid for several weeks
  • Campfire analogy

64
To Test or Not to Test
  • Is a test absolutely necessary?
  • EKG
  • Painless, safe and relatively inexpensive
  • Not absolutely needed
  • Sometimes the parent just needs a test to help
    convince them!
  • Chest x-ray
  • Depends on story more pleuritic sx
  • Radiation

65
The Non-Benign Story
  • Pressure, vise-grip substernal discomfort brought
    on only by activity (generally a predictable
    level)
  • Relieved by rest
  • Often associated with diaphoresis, nausea,
    dizziness
  • OR
  • Syncope associated with activity/pain

66
True Angina
  • Obviously this is a horse of a different color
  • Requires major work-up
  • Differential includes
  • Anomalous or aberrant coronary
  • Myocardial bridging
  • Hypertrophic cardiomyopathy
  • Coronary stenosis congenital vs acquired

67
Innocent
Murmurs
68
Innocent Murmurs
  • Quick review of the common murmurs
  • Unifying theme is that they change with position
  • High output state will accentuate the murmurs
  • Most common in the pre-school age child (except
    PPS in the newborn)

69
Normal Murmurs
  • Stills murmur
  • Innocent pulmonary flow murmur
  • Brachiocephalic murmur
  • Branch pulmonary stenosis (PPS)
  • Venous hum

70
Stills Murmur
  • Named for Frederick Still early 1900s
  • Vibratory, twangy, pretty systolic murmur best
    heard at LLSB
  • Loudest supine, soft/disappears upright
  • Grade 1 3/6
  • Typically in pre-school/school age children
  • Infant version
  • Thought to represent vibration of the great
    vessels /or LVOT

71
Innocent Pulmonary Flow Murmur
  • Systolic ejection murmur over the pulmonary area
  • Grade 1-3/6
  • May be heard in the back
  • Increases with supine position, decreases upright
  • Increased by high-output states
  • No associated click

72
Brachiocephalic Murmur
  • aka innocent cervical bruit, supraclavicular
    murmur/bruit
  • Grade 1-3/6 scratchy, harsh short SEM heard
    loudest above the right clavicle softer or
    absent below
  • No preceding click
  • May change with shoulder hyperextension
  • Can be heard over left clavicle too
  • Represents turbulent flow to the head

73
Branch Pulmonary Stenosis
  • aka Peripheral Pulmonary Stenosis (PPS)
  • Grade 1-3/6 SEM heard at base with radiation to
    axillae and back
  • No preceding click
  • Normal in infants lt6 - 9 months age
  • Usually not heard in the immediate newborn period
  • Represents turbulence at the pulmonary bifurcation

74
Venous Hum
  • Grade 1-6/6 (!) continuous very low-pitched
    murmur heard best under the clavicles
  • Loudest upright (gravity accentuates flow)
  • Loudest during diastole
  • Disappears with jugular vein pressure or supine
    position
  • Represents turbulence in the great veins from
    cerebral blood flow

75
Mammary Souffle
  • Rare in pediatrics
  • Grade 1-3/6 continuous high-pitched murmur along
    the sternum due to enlarged internal mammary
    arteries
  • Found only in lactating females

76
Conclusions
  • Syncope can generally be fully evaluated by a
    very careful history physical (/- EKG)
  • True syncope during exertion is a major red flag
  • Chest pain is common and rarely cardiac
  • True angina is rare, but obviously requires full
    evaluation
  • Innocent murmurs are common
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