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Syncope in Children. CONTINUITY CLINIC Objectives Understand the term syncope Understand the term syncope Differentiate the serious causes of syncope.

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Presentation on theme: "Syncope in Children. CONTINUITY CLINIC Objectives Understand the term syncope Understand the term syncope Differentiate the serious causes of syncope."— Presentation transcript:

1 Syncope in Children

2 CONTINUITY CLINIC Objectives Understand the term syncope Understand the term syncope Differentiate the serious causes of syncope from those that are benign 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 Know the appropriate testing needed in the evaluation of syncope based upon the presenting history

3 CONTINUITY CLINIC Definitions to Know Palpitations - sensation of strong, rapid, or irregular heart beats 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 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 Presyncope - no complete loss of consciousness occurs Syncope = syn(short) + kope (to cut)

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

7 CONTINUITY CLINIC Syncope Mimics Disorders without impairment of consciousness Disorders without impairment of consciousnessFalls Drop attacks Cataplexy Psychogenic pseudo-syncope Transient ischemic attacks Disorders with loss of consciousness Disorders with loss of consciousness Metabolic disorders EpilepsyIntoxications Vertebrobasilar transient ischemic attacks

8 CONTINUITY CLINIC Differential Diagnosis of Syncope: Seizures vs Hypotension ObservationSeizure Inadequate Perfusion OnsetSudden More gradual DurationMinutesSeconds JerksFrequentRare Headache Frequent (after) Occasional (before) Confusion after FrequentRare IncontinenceFrequentRare Eye deviation Horizontal Vertical (or none) Tongue biting FrequentRare ProdromeAuraDizziness EEG Often abnormal Usually normal

9 CONTINUITY CLINIC Causes of True Syncope Causes of True Syncope Orthostatic Cardiac Arrhythmia Structural Cardio- Pulmonary 1 Vasovagal Carotid Sinus Situational  Cough  Post- Micturition 2 Drug-Induced Autonomic Nervous System Failure  Primary  Secondary 3 Brady  SN Dysfunction  AV Block Tachy  VT  SVT Long QT Syndrome 4 Acute Myocardial Ischemia Aortic Stenosis HCM Pulmonary Hypertension Aortic Dissection Neurally- Mediated Unexplained Causes = Approximately 1/3

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

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

12 CONTINUITY CLINIC Syncope: Important Historical Features Questions about circumstances just prior to attack Position (supine, sitting, standing) Position (supine, sitting, standing) Activity (rest, change in posture, during or immediately after exercise, during or immediately after urination, defecation or swallowing) 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) 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 Nausea, vomiting, feeling cold, sweating, pain in chest

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

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

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

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

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

18 CONTINUITY CLINIC Initial Exam: Thorough Physical Vital signs Vital signs Heart rate Heart rate Orthostatic blood pressure change Orthostatic blood pressure change Cardiovascular exam: Is heart disease present? Cardiovascular exam: Is heart disease present? ECG: Long QT, pre-excitation, conduction system disease ECG: Long QT, pre-excitation, conduction system disease Echo: LV function, valve status, HCM Echo: LV function, valve status, HCM Neurological exam Neurological exam

19 CONTINUITY CLINIC 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 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. If there is only a pulse increase but no drop in blood pressure, the test is less significant.

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

21 CONTINUITY CLINIC “…cardiac syncope can be a harbinger of sudden death.” Survival with and without syncope (adults and children) Survival with and without syncope (adults and children) 6-month mortality rate of greater than 10% 6-month mortality rate of greater than 10% Cardiac syncope doubled the risk of death Cardiac syncope doubled the risk of death Includes cardiac arrhythmias Includes cardiac arrhythmias No Syncope Vasovagal/other Cardiac Cause Follow-Up (yr) Probability of Survival Soteriades ES, et al. N Engl J Med. 2002;347:878.

22 CONTINUITY CLINIC 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 CONTINUITY CLINIC 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 CONTINUITY CLINIC 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 CONTINUITY CLINIC 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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