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Syncope in Children

Syncope in Children. 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. Definitions to Know.

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Syncope in Children

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  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 Syncope = syn(short) + kope (to cut)

  4. Syncope 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

  5. Syncope 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

  6. 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?

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

  8. Differential Diagnosis of Syncope: Seizures vs Hypotension

  9. Causes of True Syncope Neurally- Mediated Orthostatic Cardiac Arrhythmia Structural Cardio- Pulmonary • 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 UnexplainedCauses = Approximately 1/3

  10. Likely Causes In Children • Vasovagal • Situational • Psychiatric • Long QT* • WPW syndrome • RV dysplasia • Hypertrophic cardiomyopathy • Catecholaminergic VT • Other genetic syndromes

  11. 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?

  12. 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

  13. 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

  14. 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)

  15. 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

  16. 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

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

  18. Initial Exam: Thorough Physical • 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

  19. 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.

  20. 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

  21. 1.0 0.8 0.6 0.4 0.2 0.0 Probability of Survival No Syncope Vasovagal/other Cardiac Cause 0 5 10 15 Follow-Up (yr) “…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. 2002;347:878.

  22. 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

  23. Laboratory 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

  24. 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

  25. 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!

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