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Morning Report

May 7, 2012

Holly Shillington, MD, PGY-2

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The Case

CC: Passed out

HPI: 17 yo male, watching a movie at

school at 0830, the next thing I knew, I

was on the floor and felt tingly. A

classmate told him he had passed out.

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HPI Cont: Total of 5 episodes of passing

out in his life: 2 month ago when hepassed out during a blood draw when sick

with mono, 2 other times also while ill, and

1 time when was well and sitting down in

school like todays episode.

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ROS

Positive for headache.

Denies head trauma, chest pain,

coughing, loss of bladder/bowel,

tonic/clonic movements, and any other

concerns.

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PMH: EBV with hepatitis and pancreatitis inFebruary, asthma, seasonal allergies, T&A

Meds: Allegra, albuterol prn NKDA IMMS: UTD

Family Hx: No seizures or sudden death. Dadhas a history of passing out a lot. Great-grandfather reportedly had an early heart attack,but lived to an old age.

Social:

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Any Other Questions?

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Any Other Questions?

Food?

- Yes. Ate breakfast. Drinking normally.

Pokeman cartoon or The Miracle of Life?

- No, watching a documentary about makingdocumentaries. (Did he pass out fromboredom?)

Any ingestions?

- Only whey protein.

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Objective

VS: T 36, HR 85, RR 18, BP 111/71,sat 94% RA, wt 100 kg

PE: Lying on the bed, texting. No acute distress.Exam, including full neuro exam, is normal.

Orthostatics:

Lying: HR 62, BP 109/62Sitting: HR 64, BP 110/43

Standing: HR 85, BP 75/51 passed out

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Differential Diagnosis ofSyncope

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Differential Diagnosis of Syncope

Neurocardiogenic(Vasovagal) Micturition, defecation

Deglutition, Cough Post-Tussive Carotid Sinus (Tight Collar) Hair Grooming

Orthostatic Hypotension

Metabolic Hypoglycemic

Neuropsychiatric Breath holding Hyperventilation

Neurologic Seizure Disorder Syncopal Migraine

Cardiac LVOT obstruction Myocardial dysfunction Arrythmias

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ED Course

BMP showed met acidosis: K 5, Cl 111,

bicarb 11, AG 17

Blood tox neg for ethanol, acetaminophen,salicylates, tricyclics.

EKG: sinus brady with normal PR, QTc

CXR: normal heart size

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ED Course

After 2 liters of fluids: Repeat BMP was normal Repeat orthostatics were normal

DX: Syncope, orthostatic hypotension

Dispo: Discharged home with cardiology follow up and

instructions to increase fluid and salt intake.

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Vasovagal Syncope

Accounts for about 75% of pediatric cases of syncope

Syncope triggered by emotional or orthostatic stress(pain, fear, heat, prolonged standing), or reflexes(micturition, defecation, swallowing, coughing, vomiting,tight collar, hair grooming)

Associated with a prodrome (nausea, pallor, diaphoresis,vertigo, visual changes tunnel vision, decreased acuity)

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Vasovagal Syncope

Mechanism: transient autonomic dysfunction which leads to acutepostural hypotension (and thus cerebral hypoperfusion)

No further testing necessary if classic presentation and absence of

red flags (syncope during exertion, personal or family hx of heartdisease)

Testing: The Tilt Table Test will show postural hypotension and thus

predisposition for vasovagal syncope. Positive: > 20 mmHg fall in systolic blood pressure or > 10 mmHg fall in

diastolic or fainting within 2-5 minutes of standing EKG to screen for cardiac causes

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Vasovagal Syncope

Management: Lie down when prodrome is recognized to prevent LOC Wear support hose to prevent venous pooling

Increase water and salt intake Eat regularly Avoid noxious stimuli Avoid alcohol, beta-blockers, tricyclics Contract leg muscles while standing to increase venous return

Medications for severe cases

Prognosis: recurs in 2/3 of cases

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References

Causes of Syncope in Children and Adolescents Up To Date. 6May 2012

Marcdante, et al. Syncope. Nelson Essentials of Pediatrics, SixthEdition. (pp. 531-533). Philadelphia: Saunders Elsevier.

Narchi, Hassib. The Child Who Passes Out. Pediatrics in Review2000; 21;384.

Reflex Syncope Up To Date. 6 May 2012 Upright Tilt Table Testing in the Evaluation of Syncope Up To

Date. 6 May 2012. Willis, John. Syncope. Pediatrics in Review2000; 21;201.