Syncope in Pediatric , diagnosis and management

Syncope in Pediatric

1. Syncope in Children

2. CONTINUITY CLINIC
Objectives
Understand the term syncope
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

3. CONTINUITY CLINIC
Definitions to Know
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
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 heart disease present or absent?
Are there important clinical features in the
history that suggest the diagnosis?

7. CONTINUITY CLINIC
Syncope Mimics
Disorders without impairment of consciousness
Falls
Drop attacks
Cataplexy
Psychogenic pseudo-syncope
Transient ischemic attacks
Disorders with loss of consciousness
Metabolic disorders
Epilepsy
Intoxications
Vertebrobasilar transient ischemic attacks

8. CONTINUITY CLINIC
Differential Diagnosis of Syncope: Seizures vs Hypotension
Observation Seizure Inadequate
Perfusion
Onset Sudden More gradual
Duration Minutes Seconds
Jerks Frequent Rare
Headache Frequent (after)Occasional (before)
Confusion afterFrequent Rare
IncontinenceFrequent Rare
Eye deviationHorizontal Vertical (or none)
Tongue bitingFrequent Rare
Prodrome Aura Dizziness
EEG Often abnormal Usually normal

9. CONTINUITY CLINIC
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
UnexplainedCauses = Approximately 1/3

10. CONTINUITY CLINIC
Likely Causes In Children
Vasovagal
Situational
Psychiatric
Long QT*
WPW syndrome
RV dysplasia
Hypertrophic cardiomyopathy
Catecholaminergic VT
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 heart disease present or absent?
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)
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)
Questions about onset of the attack
Nausea, vomiting, feeling cold, sweating, pain in chest

13. CONTINUITY CLINIC
Syncope: Important Historical
Features
Questions about attack (eye witness)
Skin color (pallor, cyanotic)
Duration of loss of consciousness
Movements ( tonic-clonic, etc.)
Tongue biting
Questions about the end of the attack
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
Family history of arrhythmic disease or sudden
death
Presence of cardiac disease
Neurological disease
Medications (Hypotensive, negative chronotropic
and antidepressant agents)

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

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

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

18. CONTINUITY CLINIC
Initial Exam: Thorough Physical
Vital signs
Heart rate
Orthostatic blood pressure change
Cardiovascular exam: Is heart disease present?
ECG: Long QT, pre-excitation, conduction system disease
Echo: LV function, valve status, HCM
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
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
Determine presence of heart disease and risk
for sudden death
Establish the cause of syncope with
sufficient certainty to:
Assess prognosis confidently
Initiate effective preventive treatment

21. CONTINUITY CLINIC
“…cardiac syncope can be a harbinger
of sudden death.”
Survival with and
without syncope (adults
and children)
6-month mortality rate
of greater than 10%
Cardiac syncope
doubled the risk
of death
Includes cardiac
arrhythmias
No Syncope
Vasovagal/other
Cardiac Cause
0 5 10 15
Follow-Up (yr)
Probability of
Survival
1.0
0.8
0.6
0.4
0.2
0.0
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!