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Syncope%20in%20Children

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Title: Syncope in Children Author: Michael Martin Last modified by: Omar Computer Created Date: 1/18/2009 11:44:56 PM Document presentation format – PowerPoint PPT presentation

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Title: Syncope%20in%20Children


1
Syncope in Children
2
Objectives
  • Understand the term syncope.
  • Differentiate the serious causes of syncope from
    those that are benign.
  • Know the appropriate testing needed in the
    evaluation of syncope based upon the presenting
    history.

3
Definitions to Know
  • Palpitations - sensation of strong, rapid, or
    irregular heart beats.
  • Syncope transient loss of consciousness and
    postural tone due to generalized cerebral
    ischemia with rapid and spontaneous recovery.
  • Presyncope - no complete loss of consciousness
    occurs.

4
Syncope Mimics
  • Disorders without impairment of consciousness
  • Drop attacks.
  • Cataplexy.
  • Psychogenic pseudo-syncope.
  • Transient ischemic attacks.
  • Disorders with loss of consciousness
  • Metabolic disorders.
  • Epilepsy.
  • Intoxications.
  • Vertebrobasilar transient ischemic attacks.

5
Syncope in children
  • Affects 15 of children between 8-18 Y
  • Uncommon under age 7 Y therefore think about
  • Seizure disorders.
  • Breath holding.
  • Primary cardiac dysrhythmias.
  • Cardiovascular causes unusual but
    life-threatening
  • Congenital malformations.
  • Valvular disease.
  • Electrical abnormalities.

6
Differential Diagnosis of Syncope Seizures vs
Hypotension
Observation Seizure Inadequate Perfusion
Onset Sudden More gradual
Duration Minutes Seconds
Jerks Frequent Rare
Headache Frequent (after) Occasional (before)
Confusion after Frequent Rare
Incontinence Frequent Rare
Eye deviation Horizontal Vertical (or none)
Tongue biting Frequent Rare
Prodrome Aura Dizziness
EEG Often abnormal Usually normal
7
Causes of True Syncope
Orthostatic
Cardiac Arrhythmia
Structural Cardio- Pulmonary
Neurally- Mediated
  • 1
  • Vasovagal
  • Carotid Sinus
  • Situational
  • Cough
  • Post-
  • Micturition
  • 2
  • Drug-Induced
  • Autonomic Nervous System Failure
  • Primary
  • Secondary
  • 4
  • Acute Myocardial Ischemia
  • Aortic Stenosis
  • HCM
  • Pulmonary Hypertension
  • Aortic Dissection
  • 3
  • Brady
  • SN Dysfunction
  • AV Block
  • Tachy
  • VT
  • SVT
  • Long QT Syndrome

Unexplained Causes Approximately 1/3
8
Likely Causes In Children
  • Vasovagal.
  • Situational.
  • Psychiatric.
  • Long QT.
  • WPW syndrome.
  • RV dysplasia.
  • Hypertrophic cardiomyopathy.
  • Catecholaminergic VT.
  • Other genetic syndromes.

9
Syncope in children
  • Vasovagal Events
  • 30 to 50 of cases.
  • Decreased PVR.
  • Decreased venous return.
  • Decreased cardiac output.
  • Hypotension.
  • Bradycardia.
  • In teens think about pregnancy and drug abuse.

10
Syncope Key questions to address with initial
evaluation
  • Is the loss of consciousness attributable to
    syncope or not?
  • Is heart disease present or absent?
  • Are there important clinical features in the
    history that suggest the diagnosis?

11
Syncope Important Historical Features
  • Questions about circumstances just prior to
    attack
  • Position (supine, sitting , standing)
  • Activity (rest, change in posture, during or
    immediately after exercise, during or immediately
    after urination, defecation or swallowing)
  • Predisposing factors (crowded or warm place,
    prolonged standing post-prandial period) and of
    precipitating events (fear, intense pain, neck
    movements)
  • Questions about onset of the attack
  • Nausea, vomiting, feeling cold, sweating, pain
    in chest

12
Syncope Important Historical Features
  • Questions about attack (eye witness)
  • Skin color (pallor, cyanotic).
  • Duration of loss of consciousness.
  • Movements ( tonic-clonic, etc.).
  • Tongue biting.
  • Questions about the end of the attack
  • Nausea, vomiting, diaphoresis, feeling cold,
    muscle aches, confusion, skin color, wounds.

13
Syncope Important Historical Feature
  • Questions about background
  • Number and duration of syncope spells.
  • Family history of arrhythmic disease or sudden
    death.
  • Presence of cardiac disease.
  • Neurological disease.
  • Medications (Hypotensive, negative. chronotropic
    and antidepressant agents).

14
Clinical Features Suggesting Specific Cause of
Syncope
  • Neurally-Mediated Syncope
  • Absence of cardiac disease.
  • Long history of syncope.
  • After sudden unexpected, unpleasant sensation.
  • Prolonged standing in crowded, hot places.
  • Nausea vomiting associated with syncope
  • During or after a meal.
  • With head rotation or pressure on carotid sinus.
  • After exertion.

15
Clinical Features Suggesting Specific Cause of
Syncope
  • Syncope due to orthostatic hypotension
  • After standing up.
  • Temporal relationship to taking a medication that
    can cause hypotension.
  • Prolonged standing.
  • Presence of autonomic neuropathy.
  • After exertion.

16
Clinical Features SuggestiNG Cause of Syncope
  • Cardiac Syncope
  • Presence of structural heart disease.
  • With exertion or supine.
  • Preceded by palpitations.
  • Family history of sudden death.

17
Initial Exam COMPLETE Physical EXAMINATION
  • Vital signs
  • Heart rate.
  • Orthostatic blood pressure change.
  • Cardiovascular exam Is heart disease present?
  • ECG Long QT, pre-excitation, conduction system
    disease.
  • Echo LV function, valve status, HCM.
  • Neurological exam.

18
Orthostatic Measurements
  • Classically, abnormal if systolic BP decreases by
    more than 20 points and/or pulse. increases in
    pulse rate of more than 20 beats per minute after
    a change from supine to standing.
  • If there is only a pulse increase but no drop in
    blood pressure, the test is less significant.

19
Diagnostic Objectives
  • Distinguish true syncope from syncope mimics.
  • Determine presence of heart disease and risk for
    sudden death.
  • Establish the cause of syncope with sufficient
    certainty to
  • Assess prognosis confidently.
  • Initiate effective preventive treatment.

20
cardiac syncope can be a harbinger of sudden
death.
  • Survival with and without syncope (adults and
    children).
  • 6-month mortality rate of greater than 10.
  • Cardiac syncope doubled the risk of death.
  • Includes cardiac arrhythmias.

Soteriades ES, et al. N Engl J Med. 2002347878.
21
Electrocardiogram
  • Yield for specific diagnosis low (5).
  • Risk free and relatively inexpensive.
  • Abnormalities (BBB, previous MI, nonsustained VT)
    guide further evaluation.
  • Recommended in almost all patients.

22
Laboratory Tests
  • Routine use not recommended
  • May be glucose?
  • Should be done only if specifically suggested by
    HP.

23
Neurologic Testing
  • EEG - not useful unless seizures.
  • Brain imaging - not useful unless focality.
  • Neurovascular studies.
  • No studies.
  • May be useful if bruits, or hx suggests
    vertebrobasilar insufficiency.

24
Final Words of Wisdom-Is it Syncope?-
  • History is key!!!!
  • Orthostatics
  • take the time to do them correctly.
  • Cardiac vs Non-cardiac
  • If you are not confident that it is NOT cardiac ?
    REFER.
  • ECG
  • Use it if you got em!

25
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26
Case study 1
  • 11-year-old girl passed out during reading
    awoke after 3 min.
  • She was stiff with eyes rolled back approx. 3
    min.
  • Now awake and alert no retractions skin color
    is normal.

27
Case study 1
  • Normal appearance, normal breathing, normal
    circulation.
  • Vital signs HR 70 RR 20 BP 90/60 T 37.7? C Wt
    39 kg O2 sat 99.
  • Three similar episodes Preceded by palpitations
    ,one of them associated with exercise.
  • PMH and FH Negative.

28
Case study 1
  • What is your general impression of this patient?

29
Clinical Features Your First Clue
  • Loss of consciousness.
  • Lasted only a few minutes.
  • Minimal or no postictal state.
  • No stigmata of seizure Urinary incontinence,
    bitten tongue, witnessed tonic-clonic activity.

30
Syncope Key questions to address with initial
evaluation
  • Is the loss of consciousness attributable to
    syncope or not?
  • Is heart disease present or absent?
  • Are there important clinical features in the
    history that suggest the diagnosis?

31
Case study 1
  • Stable
  • Patient with syncope.
  • In no distress normal exam.
  • Concerning/ominous history.
  • What are your initial management priorities?

32
Diagnostic Studies
  • Laboratory is often normal but may include
  • Electrolytes / Ca, Mg, PO4.
  • CBC with differential.
  • cardiac enzyme.
  • Radiology
  • CXR offers little.
  • CT or MRI of the brain and neck may be indicated
    if considering seizures or injury

33
Diagnostic Studies
  • ECG/Holter.
  • Echocardiography
  • Cardiac MRI
  • Continuous cardiac monitoring
  • EEG
  • Genetic testing
  • Stress ECG

34
Case study 1
  • Differntial diagnosis
  • Structural heart defect
  • Known Congenital heart disease (Ebsteins
    anomaly,LTGA,ASD)
  • Hypertrophic cardiomyopathy
  • Anomalous origin of the LCA
  • Myocarditis
  • Arrhythmogenic RV dysplasia
  • Coronary artery disease
  • Primary or secondary pulmonary hypertension.

35
Case study 1
  • Normal heart structure.
  • WPW syndrome.
  • Long or short QT syndrome.
  • Brugada syndrome.
  • CPVT.

36
Case Study 5
37
Long QT syndrome (Jervell-Nielson-Lange)
QT (corrected) QTc QT (msec)
vR-R (sec) 640/ 1.05 610 msec gt 450
m sec is long
38
Long QT Syndrome
  • Inherited genetic disorder that puts the child at
    risk for paroxysmal ventricular tachcardia
    /ventricular fibrillation and sudden death.
  • May also result from electrolyte imbalance,
    malnutrition (anorexia and bulimia), myocarditis
    and CNS trauma
  • Speculation that it may be associated with SIDS
    (unproven)
  • No warning results in death.

39
What to look for in the Department EKG
  • Long QT syndrome
  • Congenital long QT associated with hypertrophic
    cardiomyopathy.
  • Long QT defined as corrected QT longer than 0.44
    s
  • T wave alternans sometimes present.
  • Can have normal ECG in the department.
  • Two clinical syndromes not associated with
    structural heart disease Romano-Ward and
    Jervell-Lange-Nielsen.

40
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