1. Sean Mindra, MS3 Thursday July 30th, 2015
Syncope
Sean Mindra, MS3
Thursday July 30th, 2015

2. Objectives
Define syncope and review the pathophysiology and clinical manifestations
Review the differential diagnosis for syncope
Review the initial work-up and management of syncope, recognizing factors which would point to a life-threatening cause of syncope

3. Case:
ID: Tim, 14 y.o. M Reason for visit: loss of consciousness at school a few days ago HR: 72 bpm BP: 122/68 RR: 16 What is syncope and why does it occur?

4. Syncope **Complete spontaneous recovery!
What? - Sudden, abrupt loss of consciousness and tone
Why? – transient decrease in global cerebral perfusion
**Complete spontaneous recovery!

5. Why learn about syncope?
Quite common – approx. 1 out of 5 pediatric patients will experience a syncopal episode before 15 years of age
It is scary (for both patients and the parents)! – thus, very high likelihood for patients to seek medical attention following an episode
Most are benign….but our job is to learn about the more sinister causes and recognize them

6. Back to the case… ID: Tim, 14 y.o. M
Reason for visit: loss of consciousness at school a few days ago
What sorts of causes are we thinking about as we enter the examination room?

7. DDx for Syncope: Neurally-mediated syncope/NMS/ “vaso-vagal” = BENIGN!
Cardiovascularly mediated syncope
Arrythmia vs. structural
Non-cardiac pseudosyncope
Epilepsy/seizures vs. psychogenic
Drug/toxin induced
Anaphylaxis
Metabolic
Mechanical fall
Narcolepsy

8. "Listen to your patient, he is telling you the diagnosis,"
In cases of suspected syncope, the medical history is of paramount importance
Physical examination and initial investigations will generally add very little to the picture
With that in mind, what sorts of questions to you want to ask Tim?

9. History of Presenting Illness:
What were you doing at the time? Leading up to event?
Were you alone? Was it witnessed?
Prodromal symptoms?
Injuries?
Jerky movements? Post-ictal state?
Persisting neurologic deficits?
Incontinence?
Previous episodes/frequency of episodes

10. RED FLAG FEATURES History of heart murmur or congenital heart disease
Syncope during exercise/exertion
Family history of sudden cardiac death, long QT syndrome, heart disease
Long-lasting syncope
Unusual syncope triggers

11. Tim: I was at band practice, standing up for about 20 minutes
I began to feel warm, dizzy, and mildly nauseated
I then lost consciousness – my bandmates tell me I fell to the floor and was out for about 30 seconds
They told me I was “very pale and clammy”, so I had a glass of water
I felt pretty good after that but my teacher called my parents and I went home

12. Tim: What would we like to know about Tim’s past medical history?
I did not feel my heart pounding or racing
I did not feel short of breath
No chest pain or discomfort before or after the episode…I just wanted to continue with band practice
What would we like to know about Tim’s past medical history?

13. Past Medical History: Previous episodes Other medical conditions?
Seizures
Cardiac abnormalities
Insulin dependent diabetes
Anaphylaxis
**Ask for pregnancy if female

14. Tim’s Parents Say: Is Tim currently on any medications?
Tim had one other episode where he lost consciousness
This occurred about 1 year ago
He was getting bloodwork at the time and looked quite pale
Tim said that he felt quite hot and dizzy before passing out for a few seconds in the blood lab
He returned to a normal state within a few minutes of regaining consciousness
Is Tim currently on any medications?

15. Meds: Beta/calcium channel blockers Diuretics Vasodilators
Medications that prolong QT
Anti-depressants
Neuroleptics
Antibiotics
Anti-arrythmics
Zofran

16. Family History What’s next? History of syncope? Pacemaker?
Sudden cardiac death?
Prolonged QT
HOCM
MI at a young age?
What’s next?

17. Physical Examination HR: 72 bpm, BP: 122/68, RR: 16
Height: 165cm (50%ile), Weight: 44.7kg (25%ile)
Cardiac: Mild pectus excavatum. No heaves or thrills. Normal S1 and normally split S2. 1-2/6 systolic murmur at LLSB that disappeared with upright positioning. JVP normal. Femoral pulses easily palpable with no brachiofemoral delay.
Abdo: WNL.
Neuro: Non-contributory

18. Lets Review our DDx:

19. NMS
Most common (60-80%)
Often has many triggers (blood, needles, etc.)
Prodrome
No post-ictal period but can feel tired, warm, and clammy afterwards
Positive family history of fainting

20. Cardiac-mediated Syncope
Abrupt onset
Absence of usual prodromal symptoms or precipitating factors
Unusual syncope triggers (i.e. loud noises)
Is there a history of congenital heart disease
Family history of sudden cardiac death
***Typically, EXERTIONAL in nature

21. Pseudo-syncope Epilepsy vs. psychogenic Epilepsy Psychogenic
Tonic clonic movements
Tongue biting
Incontinence
Post-ictal period
Psychogenic
Conscious or unconscious avoidance of unpleasant emotional situation
Frequent episodes
Prolonged events (can be hours)
Almost never leads to injury
Can experience syncope in supine position

22. Which Investigations to Order?

23. Things to Consider: Investigations ECG Bloodwork Glucose
Holter monitor
Stress testing
EEG
CT Head
Tilt table testing

24. Tilt Table Procedure

25. Management
Reassurance! (Mainstay of therapy for NMS b/c not caused by epilepsy or a life-threatening cardiac cause)
Education
Recurrent episodes are common but most cases resolve within 5 years
Avoid triggers
Volume expansion for NMS (increasing salt and water intake)

26. For frequent, recurrent episodes refractory to conservative therapy…
Medications/pharmacotherapy
Depends on etiology/cause
Options include:
Beta blockers (Atenolol or metoprolol – mimics increased parasympathetic tone to prevent vagal output)
Alpha agonists (stimulate HR and increase peripheral resistance)
Mineralocorticoids (e.g. Florinef) for volume expansion (used along with salt/water intake)
SSRI’s (has been described for refractory syncope)