Syncope (peds): Difference between revisions

Latest revision as of 12:24, 14 May 2022

For adult patients see syncope

Background

Usually because of an abrupt cerebral hypoperfusion (30-50% from baseline)
Peak age: 15-19 years of age
In younger children, usually due to seizures, breath-holding spell or cardiac disease

Red flags

Exercise-induced collapse
Chest pain
Previous cardiac surgery
Family history of:
- Sudden Death
- Cardiac disease at early age
- Unexplained deaths
- Death due to single-vehicle accident
- Drowning
- SIDS

Clinical Features

Abrupt loss of consciousness with full recovery after a short duration

Differential Diagnosis

Syncope (peds)

Seizure
Breath-holding spell
Hyperventilation syndrome
Pregnancy (especially ectopic)
Hypoglycemia
Cardiac disease
Toxicologic exposure (stimulants or depressant)

Evaluation

Workup

ECG
Urine pregnancy (if age/sex appropriate)

Consider based on history/symptoms

CBC (or POC hemoglobin) & chemistry (or POC glucose)
TSH
Tox screen (urine or serum – based on clinical scenario)
Bedside cardiac echocardiography
- Cardiac hypertrophy or pericardial effusion
- Assess the IVC for dehydration

Diagnosis

ECG may show:
- 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
- Brugada syndrome – 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 pathognomonic (up-notching of a terminal Q wave)
- Catecholaminergic polymorphic ventricular tachycardia - May present with VT/VF due to emotional stress or a regular ECG

Management

Directed towards reversing the cause

Disposition

Admission if any ECG abnormality found
Admission usually not warranted – consider admitting kids with eating disorder
Consider discharge home with cardiology consult and strict activity restrictions if suspicion of hypertrophic cardiomyopathy in otherwise well patient with reliable caretakers

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: @@
+''For adult patients see [[syncope]]''
 ==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 hypoperfusion (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 younger children, usually due to [[seizure (peds)|seizures]], [[breath-holding spell]] or cardiac disease
+===Red flags===
+*Exercise-induced collapse
+*[[Chest pain]]
+*Previous cardiac surgery
+*Family history of:
+**Sudden Death
+**Cardiac disease at early age
+**Unexplained deaths
+**Death due to single-vehicle accident
+**[[Drowning]]
+**[[SIDS]]
 ==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:
+==Differential Diagnosis==
-#Exercise-induced collapse
+{{DDX syncope peds}}
-#Chest pain
-#Previous cardiac surgery
-#Family history of:
-##Sudden Death
-##Cardiac disease at early age? or Pacemaker?
-##Drowning
-##SIDS
-==Diagnosis==
+==Evaluation==
-#Orthostatic vital signs
+===Workup===
-#Full neurological examination (focus on Fundi, Cranial Nerves, Gait, Romberg, DTR’s and Cereberllar testing)
+*[[ECG]]
-# Any stigmata of Endocrine disorder? Marfanoid habitus? Neurological disorder (e.g. café-au-lait spots)?
+*Urine pregnancy (if age/sex appropriate)
-#Signs of an eating disorder?
-==Work-Up==
-#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)
+;Consider based on history/symptoms:
-#Beta-HCG
+*CBC (or POC hemoglobin) & chemistry (or POC glucose)
-#Serum extended electrolytes, CBC, TSH
+*TSH
-#Bedside cardiac ultrasound
+*[[Tox screen]] (urine or serum – based on clinical scenario)
-##Cardiac hypertrophy or pericardial effusion
+*Bedside cardiac [[echocardiography]]
-##Assess the IVC for dehydration
+**Cardiac hypertrophy or [[pericardial effusion]]
+**Assess the IVC for [[dehydration]]
-==DDx==
+===Diagnosis===
-#Toxicological (stimulants or depressant)
+*ECG may show:
-#CO poisoning
+**[[WPW]] – short PR, Delta waves, wide QRS
-#Breath-holding spell
+**[[Long QT syndrome]] – QTc >0.450 sec
-#Tet-spell
+**[[Hypertrophic cardiomyopathy]] – LVH, ST changes, T wave inversions, lateral leads needle like Q waves and absent R waves
+**[[Brugada syndrome]] – 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 pathognomonic (up-notching of a terminal Q wave)
+**[[Catecholaminergic polymorphic ventricular tachycardia]] - May present with VT/VF due to emotional stress or a regular ECG
-==Treatment==
+==Management==
-Directed towards reversing the cause
+*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
+*Consider discharge home with cardiology consult and strict activity restrictions if suspicion of hypertrophic cardiomyopathy in otherwise well patient with reliable caretakers
 ==See Also==
-[[Syncope]]
+*[[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:Pediatrics]]
+[[Category:Cardiology]]
+[[Category:Symptoms]]