1. Alexander Thai Emergency Medicine Resident PGY-1
Syncope
Alexander Thai
Emergency Medicine Resident PGY-1

2. Disclaimer
I have no affiliations or financial benefits from this lecture

3. Disclaimer
I have no affiliations or financial benefits from this lecture
But if you're interested in sponsoring me, I am quite available

4. 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.

5. 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?

6. 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

7. 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

8. 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

9. 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

10. Case presentation (Question 2)
So you get the EKG…

12. Diagnosis?

13. I’ll give you a clue…

14. I’ll give you a clue… Calculate the QTc

15. I’ll give you a clue… Calculate the QTc
QTc = QT/sqrt(RR)

16. QTc = QT/sqrt(RR)

17. QTc = QT/sqrt(RR)
4 big boxes = 0.8 or 800 ms
~3 big boxes = 0.6 secs or 600 ms

18. 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 = or 666ms

19. This child has prolonged QTc
Next step?

20. This child has prolonged QTc
Next step?
Cardiology consultation

21. This child has prolonged QTc
Next step?
Cardiology consultation
Treatment?

22. This child has prolonged QTc
Next step?
Cardiology consultation
Treatment?
Beta-blockers

23. So back to our main topic… Syncope

24. Syncope Defined

25. Syncope Defined

26. 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)

27. What causes syncope?

28. What causes syncope?
In peds, most common cause is vasovagal

29. 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

30. Beware of mimics

31. Beware of mimics Seizures Migraines Hyperventilation Choking games
Hysteria/conversion

32. How to evaluate?

33. 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?

34. 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

35. Other questions to think about

36. 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

37. Physical Exam

38. 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

39. 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

40. 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

41. Testing

42. Testing
#1 thing in anyone with AMS?

43. Testing
#1 thing in anyone with AMS?
Accucheck

44. 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

45. Cardiac diagnoses to look for?

46. Cardiac diagnoses to look for?
Plumbing
Electrical Problems

47. Cardiac diagnoses to look for?
Plumbing
Hypertrophic cardiomyopathy
Anomalous coronary arteries
Ventricular cardiomyopathy
Aortic Stenosis
Pulmonary HTN
Acute Myocarditis
Dilated Cardiomyopathy
Electrical Problems

48. 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)

49. Long QT

50. Long QT

51. Long QT Delayed repolarization May be familial (family hx) QTc >460
Can cause syncope -> torsades de pointes -> v. fib arrest
Treatment = beta blockers

52. Short QT

53. Short QT

54. 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

55. Brugada Pattern

56. Brugada Pattern

57. Brugada Pattern RSBB or incomplete RBBB in V1-V2 with ST elevation
At risk for monomorphic and polymorphic v. tachycardia
Ultimately need pacemakers

58. WPW

59. 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

60. Who gets cardiology consultation/follow-up?

61. 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

62. High Yield

63. 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

64. Resources 5-minute PEM consult
Spring/Spring%20Faculty%20Modules/Syncope-Faculty.pdf
Google images