Syncope (peds): Difference between revisions

Revision as of 12:10, 12 May 2015

Background

Usually because of an abrupt cerebral hypo-perfusion (30-50% from baseline)
Peak age: 15-19 years of age
In the 6 year old – usually due to seizures, breath holding or cardiac issue.

Clinical Features

Abrupt loss of consciousness with full recovery after a short duration

Red flags

Exercise-induced collapse
Chest pain
Previous cardiac surgery
Family history of:
- Sudden Death
- Cardiac disease at early age? or Pacemaker?
- Drowning
- SIDS

Differential Diagnosis

Toxicological (stimulants or depressant)
CO poisoning
Breath-holding spell
Tet-spell

Diagnosis

ECG – looking for:
- WPW – short PR, Delta waves, wide QRS
- Long QT syndrome – QTc >0.450 sec
- Hypertrophic Cardiomyopathy – LVH, ST changes, T wave inversions, lateral leads needle like Q waves and absent R waves
- Bruagada syndrome – refer to Brugada (incomplete RBBB with ST elevations in V1-3)
- Arrhythmogenic right ventricular dysplasia (ARVD) – incomplete RBBB with T waves inversion in V1-3. Epsilon wave is pathognemonic (up-notching of a terminal Q wave)

Tox screen (urine or serum – based on clinical scenario)
Beta-HCG
Serum extended electrolytes, CBC, TSH
Bedside cardiac ultrasound
- Cardiac hypertrophy or pericardial effusion
- Assess the IVC for dehydration

Management

Directed towards reversing the cause

Disposition

Admission if any ECG abnormality found
Admission usually not warranted – consider admitting kids with eating disorder

References

Fischer and Cho. Pediatric Syncope: cases from the ED. Emerg Med clin N Am. Vol 28. 2010. Pp 501-516.

Authors:

@@ Line 1: / Line 1: @@
 ==Background==
-Syncope : abrupt loss of consciousness with full recovery after a short duration. Usually because of an abrupt cerebral hypo-perfusion (30-50% from baseline) – due to brief cardiac output decrease, impaired venous return, a cardiac arrhythmia, or transient hypotension.
+*Usually because of an abrupt cerebral hypo-perfusion (30-50% from baseline)
-Peak age – 15-19 years of age, equal sex distribution. In the 6 year old – usually due to seizures, breath holding or cardiac issue.
+*Peak age: 15-19 years of age
-In total only 3% of Peds ED visits. Most are benign; 60-80% are vaso-vagal. Cardiac causes constitute 2-6%.
+*In the 6 year old – usually due to seizures, breath holding or cardiac issue.
 ==Clinical Features==
-History is key! Ask as many witnesses as possible. Pre syncope? Any jerking or tonic-clonic movement (before/during/after LOC)? Exertion? SOB? Dehydration? Heat? Last meal? Aura? Amnesia? Nausea? Diaphoresis? Menstruating? Previous cardiac surgery or procedure? Previous diagnosis of Kawasaki?
+*Abrupt loss of consciousness with full recovery after a short duration
-Medications or over-the-counter or illicit drugs?
+===Red flags===
+*Exercise-induced collapse
+*[[Chest pain]]
+*Previous cardiac surgery
+*Family history of:
+**Sudden Death
+**Cardiac disease at early age? or Pacemaker?
+**Drowning
+**[[SIDS]]
-Red flags:
+==Differential Diagnosis==
-#Exercise-induced collapse
+*Toxicological (stimulants or depressant)
-#Chest pain
+*[[CO poisoning ]]
-#Previous cardiac surgery
+*[[Breath-holding spell]]
-#Family history of:
+*[[Tet-spell]]
-##Sudden Death
-##Cardiac disease at early age? or Pacemaker?
-##Drowning
-##SIDS
 ==Diagnosis==
-#Orthostatic vital signs
+*ECG – looking for:
-#Full neurological examination (focus on Fundi, Cranial Nerves, Gait, Romberg, DTR’s and Cereberllar testing)
+** WPW – short PR, Delta waves, wide QRS
-# Any stigmata of Endocrine disorder? Marfanoid habitus? Neurological disorder (e.g. café-au-lait spots)?
+**Long QT syndrome – QTc >0.450 sec
-#Signs of an eating disorder?
+**Hypertrophic Cardiomyopathy – LVH, ST changes, T wave inversions, lateral leads needle like Q waves and absent R waves
+**Bruagada syndrome – refer to Brugada (incomplete RBBB with ST elevations in V1-3)
-==Work-Up==
+**Arrhythmogenic right ventricular dysplasia (ARVD) – incomplete RBBB with T waves inversion in V1-3. Epsilon wave is pathognemonic (up-notching of a terminal Q wave)
-#ECG – looking for:
-## WPW – short PR, Delta waves, wide QRS
-##Long QT syndrome – QTc >0.450 sec
-##Hypertrophic Cardiomyopathy – LVH, ST changes, T wave inversions, lateral leads needle like Q waves and absent R waves
-##Bruagada syndrome – refer to Brugada (incomplete RBBB with ST elevations in V1-3)
-##Arrhythmogenic right ventricular dysplasia (ARVD) – incomplete RBBB with T waves inversion in V1-3. Epsilon wave is pathognemonic (up-notching of a terminal Q wave)
-#Tox screen (urine or serum – based on clinical scenario)
-#Beta-HCG
-#Serum extended electrolytes, CBC, TSH
-#Bedside cardiac ultrasound
-##Cardiac hypertrophy or pericardial effusion
-##Assess the IVC for dehydration
-==DDx==
+*Tox screen (urine or serum – based on clinical scenario)
-#Toxicological (stimulants or depressant)
+*Beta-HCG
-#CO poisoning
+*Serum extended electrolytes, CBC, TSH
-#Breath-holding spell
+*Bedside cardiac ultrasound
-#Tet-spell
+**Cardiac hypertrophy or pericardial effusion
+**Assess the IVC for dehydration
-==Treatment==
+==Management==
 Directed towards reversing the cause
 ==Disposition==
-Cardiology consult +/- admission if any ECG abnormality found
+*Admission if any ECG abnormality found
-Admission usually not warranted – consider admitting kids with eating disorder
+*Admission usually not warranted – consider admitting kids with eating disorder
 ==See Also==
 [[Syncope]]
-==Source==
+==References==
-Fischer and Cho. Pediatric Syncope: cases from the ED. Emerg Med clin N Am. Vol 28. 2010. Pp 501-516.
+*Fischer and Cho. Pediatric Syncope: cases from the ED. Emerg Med clin N Am. Vol 28. 2010. Pp 501-516.
 [[Category:Peds]]
+[[Category:Cards]]