Approach to Syncope in Children (Pediatric Syncope).pptx

Approach to Syncope in Children (Pediatric Syncope), includes:-
Introduction
Differential diagnosis of syncope
Syncope vs vertigo vs Presyncope vs light-headedness.
Comparison of Clinical Features of Syncope and Seizures
Neurocardiogenic (Vasovagal) syncope
MECHANISMS and Causes of Syncope
Cardiac causes of syncope
Life-threatening causes of syncope
Red Flags in Evaluation of Patients With Syncope
Non-cardiac causes of loss of consciousness.
Noncardiac Causes of Syncope
Differentiating Features for Causes of Syncope
EVALUATION of syncope:- History, Examination,Treatment.
Summary

1. Approach to Syncope in Children ( Pediatric Syncope) By:- Jwan Ali Ahmed AlSofi

2. Contents:- Introduction Differential diagnosis of syncope Syncope vs vertigo vs Presyncope vs light-headedness. Comparison of Clinical Features of Syncope and Seizures Neurocardiogenic (Vasovagal) syncope MECHANISMS and Causes of Syncope Cardiac causes of syncope Life-threatening causes of syncope Red Flags in Evaluation of Patients With Syncope Non-cardiac causes of loss of consciousness. Noncardiac Causes of Syncope Differentiating Features for Causes of Syncope EVALUATION of syncope:- History, Examination,Treatment . Summary 2

3. Introduction:- Syncope is defined as a s udden transient loss of consciousness with inability to maintain postural tone with spontaneous recovery requiring no resuscitative efforts. . Presyncope or near-syncope has many or all of the prodromal symptoms without loss of consciousness . Most syncopal events are relatively benign . The most common cause of syncope in the normal pediatric population is Neurocardiogenic syncope aka ( vasovagal syncope , fainting ). Approximately 30–50% of children will have had a fainting episode before 18 yr of age . Syncope must also be distinguished from vertigo and ataxia .

4. The differential diagnosis for typical syncope includes:- Seizure Patients with epilepsy may have incontinence, marked confusion in the postictal state abnormal electroencephalograms (EEGs). Patients are rigid rather than limp may have sustained injuries. Patients do not experience the prodromal symptoms of syncope (e.g., dizziness, pallor, palpitation, and diaphoresis). The duration of unconsciousness is longer than that typically seen with syncope (<1 minute). Metabolic cause ( hypoglycemia ), The onset and recovery occur more gradually they do not occur during or shortly after meals. Hyperventilation Hyperventilation  hypocapnia  intense cerebral vasoconstriction  syncope . It may also have a psychological component. The patient often experiences air hunger , shortness of breath, chest tightness, abdominal discomfort, palpitations , dizziness, numbness or tingling of the face and extremities, and rarely loss of consciousness. The syncopal episode can be reproduced in the office when the patient hyperventilates. Atypical migraine Breath holding . Hysteria

5. Syncope and Dizziness

6. Comparison of Clinical Features of Syncope and Seizures:-

7. Although vasovagal type of syncope is very common in adolescence and has an excellent prognosis, other causes for loss of consciousness are more dangerous; thus syncope may be the first sign of more serious conditions. Indeed, the occurrence of syncope may well be the pediatrician’s best opportunity to diagnose a life-threatening condition before the patient subsequently succumbs. The task of the clinician, therefore, is not only to counsel the family and the patient concerning the common form, but also to rule out a number of important life-threatening cardiac problems . Before age 6 years , syncope is likely caused by a seizure disorder breath holding cardiac arrhythmias.

8. Neurocardiogenic (Vasovagal ) syncope 8

9. Vasovagal syncope:- Is often triggered by a specific event or situation such as pain, medical procedures, or emotional distress. Classically associated with a prodrome that includes Diaphoresis Warmth Pallor feeling lightheaded – The most common prodromal symptom is dizziness. Following the prodromal features there will be loss of motor tone . This type of syncope is characterized by hypotension and bradycardia . Once in a horizontal position, consciousness returns rapidly , in 1-2 min Some patients may have 30 sec of tonic- clonic motor activities , which should not be confused with a seizure. Postictal confusion only rarely occurs, and the rule is the occurrence of only brief postictal tiredness with a subsequent remarkable ability to resume planned activities. The physical examination is normal.

10. Vasovagal Syncope:- Prodromal features have an insidious onset and build up gradually , often arising from a state of malaise when they precede syncope. Epilepsy :- When auras with similar features precede an epileptic seizure, such features are usually sudden , short in duration , and followed by other manifestations of complex partial seizures such as stereotyped automatisms. Abdominal pain :- a common aura in temporal lobe epilepsy, Occurs in vasovagal syncope and can be a trigger or a consequence of that process (intestinal vagal hyperactivity). Most children with vasovagal syncope have an affected first-degree relative ; reports demonstrate autosomal dominant inheritance at least in some families . 10% of vasovagal syncope has Urinary incontinence 50% of vasovagal syncope has a brief period of convulsive jerks

11. MECHANISMS and Causes of Syncope:-

12. Syncope by whatever mechanism is caused by a lack of adequate cerebral blood flow with Loss of consciousness Inability to remain upright .

13. Primary cardiac causes of syncope

14. Life-Threatening Cardiac Causes as Risk With Syncope:-

15. Red Flags in Evaluation of Patients With Syncope Syncope with activity or exercise or supine Syncope not associated with prolonged standing Syncope precipitated by loud noise or extreme emotion Syncope requiring CPR Absence of presyncope or lightheadedness Injury with syncope Family history of:- Syncope, Drowning, Sudden death, Familial Ventricular arrhythmia syndromes,* cardiomyopathy Anemia Other cardiac symptoms Chest pain Dyspnea Palpitations History of cardiac surgery Kawasaki disease Implanted pacemaker Abnormal physical examination Murmur Gallop rhythm Loud and single second heart sound Systolic click Increased apical impulse (tachycardia) Irregular rhythm Hypo- or hypertension Clubbing Cyanosis

16. Non-cardiac causes of loss of consciousness include:- Epilepsy basilar artery migraine hysterical syncope Pseudoseizures Occasionally , patients with narcolepsy may present with syncope. Hypoglycemia hyperventilation.

17. Noncardiac Causes of Syncope:-

18. Differentiating Features for Causes of Syncope

19. 1. NEUROCARDIOGENIC Symptoms after prolonged motionless standing, sudden unexpected pain, fear, or unpleasant sight, sound, or smell; pallor Syncope in a well-trained athlete after exertion (without heart disease) Situational syncope during or immediately after micturition, cough, swallowing, or defecation Syncope with throat or facial pain (glossopharyngeal or trigeminal neuralgia)

20. 2. ORGANIC HEART DISEASE ( PRIMARY ARRHYTHMIA, OBSTRUCTIVE HYPERTROPHIC CARDIOMYOPATHY, PULMONARY HYPERTENSION ):- Brief sudden loss of consciousness, no prodrome , Cardiac syncope is usually sudden without the gradual onset and symptoms that accompany vagal syncope. Syncope while sitting or supine Syncope with exertion Injury because of an episode of syncope History of palpitations History of heart disease Family history of sudden death

21. 3. NEUROLOGIC:- Seizures : Preceding aura, Post event symptoms lasting > 5 min (includes postictal state of decreased level of consciousness, confusion, headache or paralysis) As a rule, children with a new-onset seizure disorder of unclear etiology should get an electrocardiogram to rule out LQT syndrome masquerading as a seizure disorder. Migraine : syncope associated with antecedent headaches with or without aura

22. 4. OTHER VASCULAR:- Carotid sinus : syncope with head rotation or pressure on the carotid sinus (as in tumors , shaving, tight collars) Orthostatic hypotension : syncope immediately on standing especially after prolonged bed rest

23. 5. DRUG INDUCED:- Patient is taking a medication that may lead to long QT syndrome, Orthostasis Bradycardia

24. 6. PSYCHIATRIC ILLNESS:- Frequent syncope somatic complaints No heart disease Syncope resulting from hysteria is not associated with injury and occurs only in the presence of an audience. During these attacks the patient does not experience the pallor and hypotension that characterize true syncope. The attacks may last longer (up to an hour) than a brief syncopal spell. Episodes usually occur in an emotionally charged setting and are rare before 10 years of age.

25. EVALUATION

26. The most important goal in the evaluation of the new patient with syncope is to diagnose life-threatening causes of syncope so that these causes can be managed. Many patients presenting with sudden cardiac arrest caused by conditions such as LQTS will have previously experienced an episode of syncope, so the presentation with syncope is an opportunity to prevent sudden death.

27. The most important tool in evaluation is a careful history:- The characteristics of cardiac syncope differ significantly from the prodrome seen in neurocardiogenic syncope. Several red flags can be identified that should lead the clinician to suspect that the mechanism is a life-threatening cardiac cause rather than simple fainting. The occurrence during exercise suggests an arrhythmia or coronary obstruction. Injury because of an episode of syncope indicates sudden occurrence with a lack of adequate prodromal symptoms and suggests an arrhythmia. The occurrence of syncope while recumbent would be quite unusual in a patient with neurocardiogenic syncope and therefore suggests a cardiac or neurologic cause. Occasionally , a patient with syncope caused by a tachyarrhythmia will report the sensation of a racing heart before the event , but this is unusual.

28. A careful family history is essential in evaluation of syncope . if there are first-degree relatives with inherited syndromes , such as a LQTS or HCM, this should lead to more specific evaluation of the patient. if relatives died suddenly at a young age without a clear and convincing cause , inherited cardiac arrhythmias or cardiomyopathies should also be suspected.

29. Patients with a history of heart disease, especially cardiac repair , may have causes that are specific to their repair:- Sinus node dysfunction is common after the Senning or Mustard procedure for transposition of the great vessels. VT may be seen after repair of tetralogy of Fallot . A patient with a history of septal defect repair should be evaluated for the late occurrence of AV block. patients with an implanted pacemaker should be evaluated for pacemaker lead failure.

30. The physical examination may also offer clues:- Patients with HCM as will patients with aortic stenosis may have:- a prominent cardiac impulse an ejection murmur ,. The patient with primary pulmonary hypertension will have:- a loud and single second heart sound an ejection click the murmur of pulmonary insufficiency. Scars from prior cardiac surgery and pacemaker implantation would be evident.

31. Investigations:- All patients presenting with a first episode of syncope must have an ECG obtained, looking primarily for QT interval prolongation , Preexcitation ventricular hypertrophy T-wave abnormalities conduction abnormalities. Other tests that may be needed depending on the results of the initial evaluation may include echocardiography , exercise testing, cardiac MRI 24 hr Holter monitoring. In patients for whom there is a strong suspicion of a paroxysmal arrhythmia, an implantable loop recorder may be the most effective means of diagnosis.

32. Investigations:- Additional tests to look for Anemia Hypoglycemia drugs of abuse other etiologies will be determined by the history and physical examination.

33. Head-up tilt table test:- If patients with positional syncope have autonomic symptoms (such as pallor, diaphoresis, or hyperventilation), a tilt table test is sometimes performed by some centers . Vasovagal : an abrupt decrease in BP usually with bradycardia leading to syncope Dysautonomia (or postural hypotension): a gradual decrease in BP without an increase in heart rate, leading to syncope POTS : an excessive increase in heart rate to maintain an adequate BP to prevent syncope 35

34. 36 Schematic drawing of changes in heart rate (HR) and systolic blood pressure (BP) observed during the head-up tilt test . Thin arrows mark the start of orthostatic stress. Large unfilled arrows indicate appearance of symptoms with changes seen in HR and BP. POTS, postural orthostatic tachycardia syndrome .

35. TREATMENT 38

36. Therapy for vasovagal syncope includes:- avoiding triggering events (if possible ) fluid and salt supplementation if needed, midodrine – alpha-adrenergic agonist, vasopressor. Immediately after the event, the patient should remain supine until symptoms abate to avoid recurrence.

37. Treatment for cardiac causes of syncope will be determined by the diagnosis:- If a reentrant tachycardia (AVNRT, AVRT) is found, then a catheter ablation is indicated. If bradycardia from AV block was the cause of the syncope, a pacemaker may be warranted. Patients with syncope from medically refractory malignant arrhythmias, as may be seen in HCM, LQTS, arrhythmogenic cardiomyopathy, or CPVT, require an implantable cardioverter-defibrillator . Patients with structural heart disease ( valvular disease or coronary artery anomalies) should be referred for surgery .

38. Summary:- Syncope is the transient loss of consciousness and muscle tone and is typically associated with an upright position , prodromal symptoms, pale appearance, and brief loss of consciousness with rapid return to normal state of consciousness. Syncope occurring during exercise or with associated cardiac symptoms should be considered atypical until more extensively evaluated.

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