Syncope in Syncope in ChildrenChildren

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

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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)

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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

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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

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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?

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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

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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

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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

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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

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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?

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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

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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

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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)

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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

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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

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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

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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

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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.

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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

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“…“…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

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0.8

0.6

0.4

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Soteriades ES, et al. N Engl J Med. 2002;347:878.

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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

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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

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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

CONTINUITY CLINIC

Final Words of WisdomFinal Words of Wisdom-Is it Syncope?--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!