Alexander Thai Emergency Medicine Resident PGY1 Disclaimer I have no affiliations or financial benefits from this lecture Disclaimer I have no affiliations or financial benefits from this lecture ID: 539920
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Syncope
Alexander ThaiEmergency Medicine Resident PGY-1Slide2
Disclaimer
I have no affiliations or financial benefits from this lectureSlide3
Disclaimer
I have no affiliations or financial benefits from this lectureBut if you're interested in sponsoring me, I am quite availableSlide4
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.Slide5
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?Slide6
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 syncopeSlide7
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?
Cardiac event monitoring
CT scan of the brain
Electrocardiography
Electroencephalography
Tilt Table
Testing
EchocardiographySlide8
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?
Cardiac event monitoring
CT scan of the brain
Electrocardiography
Electroencephalography
Tilt Table
Testing
EchocardiographySlide9
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 findingsSlide10
Case presentation (Question 2)
So you get the EKG…Slide11Slide12
Diagnosis?Slide13
I’ll give you a clue…Slide14
I’ll give you a clue…
Calculate the QTcSlide15
I’ll give you a clue…
Calculate the QTc
QTc = QT/sqrt(RR)Slide16
QTc = QT/sqrt(RR)Slide17
QTc = QT/sqrt(RR)
4 big boxes = 0.8 or 800 ms
~3 big boxes = 0.6 secs or 600 msSlide18
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 666msSlide19
This child has prolonged QTc
Next step?Slide20
This child has prolonged QTc
Next step?Cardiology consultationSlide21
This child has prolonged QTc
Next step?Cardiology consultation
Treatment?Slide22
This child has prolonged QTc
Next step?Cardiology consultation
Treatment?
Beta-blockersSlide23
So back to our main topic… SyncopeSlide24
Syncope DefinedSlide25
Syncope DefinedSlide26
Syncope Defined
Brief sudden loss of consciousness with loss of postural tone that resolves spontaneouslyPre-syncope refers to feeling faint without true loss of consciousness
Literature reports occurs in 15-50% of adolescents
(highly sensitive literature)Slide27
What causes syncope?Slide28
What causes syncope?
In peds, most common cause is vasovagalSlide29
What causes syncope?
In peds, most common cause is vasovagalHowever, your job is to rule out the life threatening causes
Dysrhythmias (usually tachydysrhythmias)
Cardiac outflow obstructions
Toxic exposures
Hypoglycemia
Ectopic pregnancySlide30
Beware of mimicsSlide31
Beware of mimics
SeizuresMigrainesHyperventilation
Choking games
H
ysteria/conversionSlide32
How to evaluate?Slide33
How to evaluate?
HistoryWhat 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?Slide34
How to evaluate?
HistoryWhat 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 diseaseSlide35
Other questions to think aboutSlide36
Other questions to think about
Additional hxMenstrual history
Medical problems
Access to medications/illicit drugs
Family history
Early cardiac death before 45
Known arrhythmia
Familial cardiomyopathySlide37
Physical ExamSlide38
Physical Exam
OrthostaticsChange from sitting to standing (decrease in SBP >20 or HR increase>20
More importantly, does this recreate symptoms?
Normal does not exclude cardiac dysrhythmiasSlide39
Physical Exam
OrthostaticsChange 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 failureSlide40
Physical Exam
OrthostaticsChange 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 thoroughlySlide41
TestingSlide42
Testing
#1 thing in anyone with AMS?Slide43
Testing
#1 thing in anyone with AMS?AccucheckSlide44
Testing
#1 thing in anyone with AMS?AccucheckECG
Urine Preg
Hgb
Urine drug screen (if still altered)
No neurologic imaging indicated unless persistent focal neurologic abnormalitySlide45
Cardiac diagnoses to look for?Slide46
Cardiac diagnoses to look for?
Plumbing
Electrical ProblemsSlide47
Cardiac diagnoses to look for?
PlumbingHypertrophic cardiomyopathy
Anomalous coronary arteries
Ventricular cardiomyopathy
Aortic Stenosis
Pulmonary HTN
Acute Myocarditis
Dilated Cardiomyopathy
Electrical ProblemsSlide48
Cardiac diagnoses to look for?
PlumbingHypertrophic cardiomyopathy
Anomalous coronary arteries
Ventricular cardiomyopathy
Aortic Stenosis
Pulmonary HTN
Acute Myocarditis
Dilated Cardiomyopathy
Electrical Problems
Long QT
Brugada
Polymorphic VT
Pre-excitation (WPW)Slide49
Long QTSlide50
Long QTSlide51
Long QT
Delayed repolarizationMay be familial (family hx)QTc >460
Can cause syncope -> torsades de pointes -> v. fib arrest
Treatment = beta blockersSlide52
Short QTSlide53
Short QTSlide54
Short QT
QTc < 320Increased incidence of atrial fibrillationMay indicate an electrolyte abnormality (hypercalcemia for example)
High risk of ventricular dysrhythmia and sudden cardiac deathSlide55
Brugada
PatternSlide56
Brugada
PatternSlide57
Brugada
PatternRSBB or incomplete RBBB in V1-V2 with ST elevation
At risk for monomorphic and polymorphic v. tachycardia
Ultimately need pacemakers Slide58
WPWSlide59
WPW
Short PR interval and delta wave are diagnosticRepresents 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… SHOCKSlide60
Who gets cardiology consultation/follow-up?Slide61
Who gets cardiology consultation/follow-up?
Family hx of sudden death or malignant arrhythmiaExercise related syncope
Cardiac history
If abnormal ECG, fax to cardiology (or text at Holtz) for an interpretation prior to admitting patientSlide62
High YieldSlide63
High Yield
If pt at baseline, little need for extensive workupScreening 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 signSlide64
Resources
5-minute PEM consulthttp://
www.nccpeds.com/ContinuityModules-Spring/Spring%20Faculty%20Modules/Syncope-Faculty.pdf
http://
www.slideshare.net/Odigia/syncope-17173349
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