Download 11/4/16 - ERS 4 KIDS

Syncope
Alexander Thai
Emergency Medicine Resident PGY-1
Disclaimer
 I have no affiliations or financial benefits from this lecture
Disclaimer
 I have no affiliations or financial benefits from this lecture
 But if you're interested in sponsoring me, I am quite available
Case presentation
 Holtz is a 12-year-old male who presents for his sports physical prior to trying
out for a traveling soccer team. During your history-taking, he admits to
fainting last week during a soccer practice. He thought it was due to
possible dehydration so he never mentioned it to his parents. When asked
further about this episode, he recalls that he was running on the field then
suddenly collapsed. He was unconscious for about a minute and “came
to” when his teammates roused him. No previous episodes of fainting. Mom
reports that her brother (Holtz’s uncle) died of drowning when he was a
teenager.
Case presentation
 Holtz is a 12-year-old male who presents for his sports physical prior to trying
out for a traveling soccer team. During your history-taking, he admits to
fainting last week during a soccer practice. He thought it was due to
possible dehydration so he never mentioned it to his parents. When asked
further about this episode, he recalls that he was running on the field then
suddenly collapsed. He was unconscious for about a minute and “came
to” when his teammates roused him. No previous episodes of fainting. Mom
reports that her brother (Holtz’s uncle) died of drowning when he was a
teenager.
 Are you concerned about Jack? Why or why not?
Case presentation
 Holtz is a 12-year-old male who presents for his sports physical prior to trying
out for a traveling soccer team. During your history-taking, he admits to
fainting last week during a soccer practice. He thought it was due to
possible dehydration so he never mentioned it to his parents. When asked
further about this episode, he recalls that he was running on the field then
suddenly collapsed. He was unconscious for about a minute and “came
to” when his teammates roused him. No previous episodes of fainting. Mom
reports that her brother (Holtz’s uncle) died of drowning when he was a
teenager.
 Are you concerned about Jack? Why or why not?
 Yes. Red flags: Syncope with exertion, family history of possible sudden cardiac death –
both concerning for etiology of syncope
Case presentation (Question 1)
 Holtz is a 12-year-old male who presents for his sports physical prior to trying
out for a traveling soccer team. During your history-taking, he admits to
fainting last week during a soccer practice. He thought it was due to
possible dehydration so he never mentioned it to his parents. When asked
further about this episode, he recalls that he was running on the field then
suddenly collapsed. He was unconscious for about a minute and “came
to” when his teammates roused him. No previous episodes of fainting. Mom
reports that her brother (Holtz’s uncle) died of drowning when he was a
teenager.

What is the next step in management?
A.
Cardiac event monitoring
B.
CT scan of the brain
C.
Electrocardiography
D.
Electroencephalography
E.
Tilt Table Testing
F.
Echocardiography
Case presentation (Question 1)
 Holtz is a 12-year-old male who presents for his sports physical prior to trying
out for a traveling soccer team. During your history-taking, he admits to
fainting last week during a soccer practice. He thought it was due to
possible dehydration so he never mentioned it to his parents. When asked
further about this episode, he recalls that he was running on the field then
suddenly collapsed. He was unconscious for about a minute and “came
to” when his teammates roused him. No previous episodes of fainting. Mom
reports that her brother (Holtz’s uncle) died of drowning when he was a
teenager.

What is the next step in management?
A.
Cardiac event monitoring
B.
CT scan of the brain
C.
Electrocardiography
D.
Electroencephalography
E.
Tilt Table Testing
F.
Echocardiography
Case presentation (Question 1)
 Electrocardiography should be a part of the initial evaluation for all patients
who presents with syncope.
 Why not the others?
 Cardiac event monitoring, tilt table testing, and an echo are usually done after
an abnormal ECG and a cardiology consultation has been done
 Neuro-imaging not indicated if pt does not present with focal neurologic findings
Case presentation (Question 2)
 So you get the EKG…
Diagnosis?
I’ll give you a clue…
I’ll give you a clue…
Calculate the QTc
I’ll give you a clue…
Calculate the QTc
QTc = QT/sqrt(RR)
QTc = QT/sqrt(RR)
QTc = QT/sqrt(RR)
4 big boxes = 0.8 or 800 ms
~3 big boxes = 0.6 secs or 600 ms
QTc = QT/sqrt(RR)
4 big boxes = 0.8 or 800 ms
~3 big boxes = 0.6 secs or 600 ms
QTc = 0.6/0.9 = 0.666 or 666ms
This child has prolonged QTc
 Next step?
This child has prolonged QTc
 Next step?
 Cardiology consultation
This child has prolonged QTc
 Next step?
 Cardiology consultation
 Treatment?
This child has prolonged QTc
 Next step?
 Cardiology consultation
 Treatment?
 Beta-blockers
So back to our main topic… Syncope
Syncope Defined
Syncope Defined
Syncope Defined
 Brief sudden loss of consciousness with loss of postural tone that resolves
spontaneously
 Pre-syncope refers to feeling faint without true loss of consciousness
 Literature reports occurs in 15-50% of adolescents
 (highly sensitive literature)
What causes syncope?
What causes syncope?
 In peds, most common cause is vasovagal
What causes syncope?
 In peds, most common cause is vasovagal
 However, your job is to rule out the life threatening causes
 Dysrhythmias (usually tachydysrhythmias)
 Cardiac outflow obstructions
 Toxic exposures
 Hypoglycemia
 Ectopic pregnancy
Beware of mimics
Beware of mimics
 Seizures
 Migraines
 Hyperventilation
 Choking games
 Hysteria/conversion
How to evaluate?
How to evaluate?
 History
 What was happening around pt?
 Feeling/sensation before event?
 What position was pt in when it
happened?
 Did pt have chest pain or HA
before/after?
 Witness?
How to evaluate?
 History
 What was happening around pt?
 Feeling/sensation before event?
 What position was pt in when it
happened?
 Did pt have chest pain or HA
before/after?
 Witness?
 Warning signs!
 Triggered by fright or sound
 No prodrome
 Exertional
 Palpations or chest pain
 Brief posturing
 Family history of sudden
cardiac death, known
arrhythmia
 Congenital heart disease
Other questions to think about
Other questions to think about
 Additional hx
 Menstrual history
 Medical problems
 Access to medications/illicit drugs
 Family history
 Early cardiac death before 45
 Known arrhythmia
 Familial cardiomyopathy
Physical Exam
Physical Exam
 Orthostatics
 Change from sitting to standing (decrease in SBP >20 or HR increase>20
 More importantly, does this recreate symptoms?
 Normal does not exclude cardiac dysrhythmias
Physical Exam
 Orthostatics
 Change from sitting to standing (decrease in SBP >20 or HR increase>20
 More importantly, does this recreate symptoms?
 Normal does not exclude cardiac dysrhythmias
 Full physical exam with emphasis on:
 Detailed neurologic exam
 Cardiac exam
 Murmurs, gallops, and rubs
 Signs of heart failure
Physical Exam
 Orthostatics
 Change from sitting to standing (decrease in SBP >20 or HR increase>20
 More importantly, does this recreate symptoms?
 Normal does not exclude cardiac dysrhythmias
 Full physical exam with emphasis on:
 Detailed neurologic exam
 Cardiac exam
 Murmurs, gallops, and rubs
 Signs of heart failure
 Document thoroughly
Testing
Testing
 #1 thing in anyone with AMS?
Testing
 #1 thing in anyone with AMS?
 Accucheck
Testing
 #1 thing in anyone with AMS?
 Accucheck
 ECG
 Urine Preg
 Hgb
 Urine drug screen (if still altered)
 No neurologic imaging indicated unless persistent focal neurologic
abnormality
Cardiac diagnoses to look for?
Cardiac diagnoses to look for?
 Plumbing
 Electrical Problems
Cardiac diagnoses to look for?
 Plumbing
 Hypertrophic cardiomyopathy
 Anomalous coronary arteries
 Ventricular cardiomyopathy
 Aortic Stenosis
 Pulmonary HTN
 Acute Myocarditis
 Dilated Cardiomyopathy
 Electrical Problems
Cardiac diagnoses to look for?
 Plumbing
 Hypertrophic cardiomyopathy
 Anomalous coronary arteries
 Ventricular cardiomyopathy
 Aortic Stenosis
 Pulmonary HTN
 Acute Myocarditis
 Dilated Cardiomyopathy
 Electrical Problems
 Long QT
 Brugada
 Polymorphic VT
 Pre-excitation (WPW)
Long QT
Long QT
Long QT
 Delayed repolarization
 May be familial (family hx)
 QTc >460
 Can cause syncope -> torsades de pointes -> v. fib arrest
 Treatment = beta blockers
Short QT
Short QT
Short QT
 QTc < 320
 Increased incidence of atrial fibrillation
 May indicate an electrolyte abnormality (hypercalcemia for example)
 High risk of ventricular dysrhythmia and sudden cardiac death
Brugada Pattern
Brugada Pattern
Brugada Pattern
 RSBB or incomplete RBBB in V1-V2 with ST elevation
 At risk for monomorphic and polymorphic v. tachycardia
 Ultimately need pacemakers
WPW
WPW
 Short PR interval and delta wave are diagnostic
 Represents signal transmitting around the AV node through bundle of Kent
 Can go into tachydysrhythmias… Beware… can be wide complex irregular
tachycardia
 If stable may want to discuss with cardiology prior to drug administration as
adenosine and diltiazem can be problematic
 Unstable… SHOCK
Who gets cardiology
consultation/follow-up?
Who gets cardiology
consultation/follow-up?
 Family hx of sudden death or malignant arrhythmia
 Exercise related syncope
 Cardiac history
 If abnormal ECG, fax to cardiology (or text at Holtz) for an interpretation
prior to admitting patient
High Yield
High Yield
 If pt at baseline, little need for extensive workup
 Screening ECG, through low yield, will screen for most life-threatening
cardiac syncope
 Look for anemia, hypoglycemia
 Always check U-preg
 No indication for ED neuro-imaging in a child without focal neurological
sign
Resources
 5-minute PEM consult
 http://www.nccpeds.com/ContinuityModulesSpring/Spring%20Faculty%20Modules/Syncope-Faculty.pdf
 http://www.slideshare.net/Odigia/syncope-17173349
 Google images