syncope in children. continuity clinic objectives understand the term syncope understand the term...
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CONTINUITY CLINIC
ObjectivesObjectives
Understand the term syncopeUnderstand the term syncope
Differentiate the serious causes of Differentiate the serious causes of syncope from those that are benignsyncope from those that are benign
Know the appropriate testing Know the appropriate testing needed in the evaluation of syncope needed in the evaluation of syncope based upon the presenting historybased upon the presenting history
CONTINUITY CLINIC
Definitions to KnowDefinitions to Know
PalpitationsPalpitations - sensation of strong, - sensation of strong, rapid, or irregular heart beatsrapid, or irregular heart beats
SyncopeSyncope – transient loss of – transient loss of consciousness and postural tone due consciousness and postural tone due to generalized cerebral ischemia with to generalized cerebral ischemia with rapid and spontaneous recoveryrapid and spontaneous recovery
PresyncopePresyncope - no complete loss of - no complete loss of consciousness occursconsciousness occurs
Syncope = syn(short) + kope (to cut)Syncope = syn(short) + kope (to cut)
CONTINUITY CLINIC
Syncope in childrenSyncope in children Affects 15% of children between 8-18 Uncommon under age 7 therefore think
about: Seizure disorders Breath holding Primary cardiac dysrhythmias
Cardiovascular causes unusual but life-threatening anatomic abnormalities congenital malformations valvular disease electrical abnormalities
CONTINUITY CLINIC
Syncope in childrenSyncope in children
Vasovagal Events 32% to 50% of cases Decreased PVR Decreased venous return Decreased cardiac output Hypotension Bradycardia
In teens – think about pregnancy and drugs of abuse
CONTINUITY CLINIC
Syncope: Key questions to Syncope: Key questions to address with initial evaluationaddress with initial evaluation
Is the loss of consciousness Is the loss of consciousness attributable to syncope or not?attributable to syncope or not?
Is heart disease present or absent?Is heart disease present or absent?
Are there important clinical features Are there important clinical features in the history that suggest the in the history that suggest the diagnosis?diagnosis?
CONTINUITY CLINIC
Syncope MimicsSyncope MimicsDisorders without impairment of Disorders without impairment of consciousnessconsciousness
Falls Falls
Drop attacksDrop attacks
CataplexyCataplexy
Psychogenic pseudo-syncopePsychogenic pseudo-syncope
Transient ischemic attacksTransient ischemic attacksDisorders with loss of consciousnessDisorders with loss of consciousness
Metabolic disordersMetabolic disorders
EpilepsyEpilepsy
IntoxicationsIntoxications
Vertebrobasilar transient ischemic attacksVertebrobasilar transient ischemic attacks
CONTINUITY CLINIC
Differential Diagnosis of Syncope: Seizures vs Differential Diagnosis of Syncope: Seizures vs HypotensionHypotension
ObservationObservation SeizureSeizure Inadequate Inadequate PerfusionPerfusion
OnsetOnset SuddenSudden More gradualMore gradual
DurationDuration MinutesMinutes SecondsSeconds
JerksJerks FrequentFrequent RareRare
HeadacheHeadache Frequent (after)Frequent (after) Occasional Occasional (before)(before)
Confusion Confusion afterafter
FrequentFrequent RareRare
IncontinenceIncontinence FrequentFrequent RareRare
Eye deviationEye deviation HorizontalHorizontal Vertical (or Vertical (or none)none)
Tongue bitingTongue biting FrequentFrequent RareRare
ProdromeProdrome AuraAura DizzinessDizziness
EEGEEG Often abnormalOften abnormal Usually normalUsually normal
CONTINUITY CLINIC
Causes of True SyncopeCauses of True Syncope
OrthostaticOrthostatic CardiacArrhythmia
CardiacArrhythmia
StructuralCardio-
Pulmonary
StructuralCardio-
Pulmonary
1• Vasovagal• Carotid Sinus• Situational
CoughPost- Micturition
2• Drug-Induced• Autonomic
Nervous System FailurePrimarySecondary
3• Brady
SN Dysfunction
AV Block
• TachyVTSVT
• Long QT Syndrome
4 • Acute
Myocardial Ischemia
• Aortic Stenosis
• HCM• Pulmonary
Hypertension• Aortic
Dissection
Neurally-Mediated
Neurally-Mediated
Unexplained Causes = Approximately 1/3Unexplained Causes = Approximately 1/3
CONTINUITY CLINIC
Likely Causes In Likely Causes In ChildrenChildren
VasovagalVasovagal SituationalSituational PsychiatricPsychiatric Long QT*Long QT* WPW syndromeWPW syndrome RV dysplasiaRV dysplasia Hypertrophic cardiomyopathyHypertrophic cardiomyopathy Catecholaminergic VTCatecholaminergic VT Other genetic syndromesOther genetic syndromes
CONTINUITY CLINIC
Syncope: Key questions to Syncope: Key questions to address with initial evaluationaddress with initial evaluation
Is the loss of consciousness Is the loss of consciousness attributable to syncope or not?attributable to syncope or not?
Is heart disease present or absent?Is heart disease present or absent?
Are there important clinical features Are there important clinical features in the history that suggest the in the history that suggest the diagnosis?diagnosis?
CONTINUITY CLINIC
Syncope: Important Syncope: Important Historical FeaturesHistorical Features
Questions about circumstances just prior to Questions about circumstances just prior to attackattack
Position (supine, sitting , standing)Position (supine, sitting , standing) Activity (rest, change in posture, during or Activity (rest, change in posture, during or
immediately after exercise, during or immediately immediately after exercise, during or immediately after urination, defecation or swallowing)after urination, defecation or swallowing)
Predisposing factors (crowded or warm place, Predisposing factors (crowded or warm place, prolonged standing post-prandial period) and of prolonged standing post-prandial period) and of precipitating events (fear, intense pain, neck precipitating events (fear, intense pain, neck movements)movements)
Questions about onset of the attackQuestions about onset of the attack Nausea, vomiting, feeling cold, sweating, pain in chestNausea, vomiting, feeling cold, sweating, pain in chest
CONTINUITY CLINIC
Syncope: Important Syncope: Important Historical FeaturesHistorical Features
Questions about attack (eye witness)Questions about attack (eye witness) Skin color (pallor, cyanotic)Skin color (pallor, cyanotic) Duration of loss of consciousnessDuration of loss of consciousness Movements ( tonic-clonic, etc.)Movements ( tonic-clonic, etc.) Tongue bitingTongue biting
Questions about the end of the attackQuestions about the end of the attack Nausea, vomiting, diaphoresis, feeling Nausea, vomiting, diaphoresis, feeling
cold, muscle aches, confusion, skin color, cold, muscle aches, confusion, skin color, woundswounds
CONTINUITY CLINIC
Syncope: Important Syncope: Important Historical FeatureHistorical Feature
Questions about backgroundQuestions about background Number and duration of syncope spellsNumber and duration of syncope spells Family history of arrhythmic disease or Family history of arrhythmic disease or
sudden deathsudden death Presence of cardiac diseasePresence of cardiac disease Neurological disease Neurological disease Medications (Hypotensive, negative Medications (Hypotensive, negative
chronotropic and antidepressant chronotropic and antidepressant agents)agents)
CONTINUITY CLINIC
Clinical Features Suggesting Clinical Features Suggesting Specific Cause of SyncopeSpecific Cause of Syncope
Neurally-Mediated SyncopeNeurally-Mediated Syncope Absence of cardiac diseaseAbsence of cardiac disease Long history of syncopeLong history of syncope After sudden unexpected, unpleasant After sudden unexpected, unpleasant
sensationsensation Prolonged standing in crowded, hot placesProlonged standing in crowded, hot places Nausea vomiting associated with syncopeNausea vomiting associated with syncope During or after a mealDuring or after a meal With head rotation or pressure on carotid With head rotation or pressure on carotid
sinussinus After exertionAfter exertion
CONTINUITY CLINIC
Clinical Features Suggesting Clinical Features Suggesting Specific Cause of SyncopeSpecific Cause of Syncope
Syncope due to orthostatic Syncope due to orthostatic hypotensionhypotension
After standing upAfter standing up Temporal relationship to taking a Temporal relationship to taking a
medication that can cause hypotensionmedication that can cause hypotension Prolonged standingProlonged standing Presence of autonomic neuropathyPresence of autonomic neuropathy After exertionAfter exertion
CONTINUITY CLINIC
Clinical Features Suggestion Clinical Features Suggestion Cause of SyncopeCause of Syncope
Cardiac SyncopeCardiac Syncope Presence of structural heart Presence of structural heart
diseasedisease With exertion or supineWith exertion or supine Preceded by palpitationsPreceded by palpitations Family history of sudden deathFamily history of sudden death
CONTINUITY CLINIC
Initial Exam: Thorough Initial Exam: Thorough PhysicalPhysical
Vital signsVital signs Heart rateHeart rate Orthostatic blood pressure changeOrthostatic blood pressure change
Cardiovascular exam: Is heart disease Cardiovascular exam: Is heart disease present? present? ECG: Long QT, pre-excitation, conduction ECG: Long QT, pre-excitation, conduction
system diseasesystem disease Echo: LV function, valve status, HCMEcho: LV function, valve status, HCM
Neurological examNeurological exam
CONTINUITY CLINIC
Orthostatic Orthostatic MeasurementsMeasurements
Classically, abnormal if systolic BP Classically, abnormal if systolic BP decreases by more than 20 points decreases by more than 20 points and/or pulse increases in pulse rate and/or pulse increases in pulse rate of more than 20 beats per minute of more than 20 beats per minute after a change from supine to after a change from supine to standingstanding
If there is only a pulse increase but If there is only a pulse increase but no drop in blood pressure, the test is no drop in blood pressure, the test is less significant. less significant.
CONTINUITY CLINIC
Diagnostic ObjectivesDiagnostic Objectives
Distinguish true syncope from Distinguish true syncope from syncope mimicssyncope mimics
Determine presence of heart Determine presence of heart disease and risk for sudden deathdisease and risk for sudden death
Establish the cause of syncope with Establish the cause of syncope with sufficient certainty to:sufficient certainty to: Assess prognosis confidentlyAssess prognosis confidently Initiate effective preventive treatmentInitiate effective preventive treatment
CONTINUITY CLINIC
“…“…cardiac syncope can be a cardiac syncope can be a harbinger of sudden death.”harbinger of sudden death.”
Survival with and Survival with and without syncope without syncope (adults and children)(adults and children)
6-month mortality 6-month mortality rate rate of greater than 10%of greater than 10%
Cardiac syncope Cardiac syncope doubled the risk doubled the risk of deathof death
Includes cardiac Includes cardiac arrhythmias arrhythmias
No SyncopeVasovagal/otherCardiac Cause
0 5 1015Follow-Up (yr)
Pro
bab
ility
of
Sur
viva
l
1.0
0.8
0.6
0.4
0.2
0.0
Soteriades ES, et al. N Engl J Med. 2002;347:878.
CONTINUITY CLINIC
ElectrocardiogramElectrocardiogram
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
CONTINUITY CLINIC
Laboratory TestsLaboratory Tests
Routine use not recommended Maybe glucose?
Should be done only if specifically suggested by H&P
Pregnancy testing should be considered in women of child-bearing age
CONTINUITY CLINIC
Neurologic TestingNeurologic 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