Alexander Thai Emergency Medicine Resident PGY-1 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? Cardiac event monitoring CT scan of the brain Electrocardiography Electroencephalography Tilt Table Testing 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? Cardiac event monitoring CT scan of the brain Electrocardiography Electroencephalography Tilt Table Testing 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 Warning signs! Triggered by fright or sound 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 Full physical exam with emphasis on: 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 Full physical exam with emphasis on: 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? ECG Urine Preg Hgb 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/ContinuityModules- Spring/Spring%20Faculty%20Modules/Syncope-Faculty.pdf http://www.slideshare.net/Odigia/syncope-17173349 Google images