1. Syncope in Children

2. Objectives Understand the term syncope
Differentiate the serious causes of syncope from those that are benign
Know the appropriate testing needed in the evaluation of syncope based upon the presenting history

3. Syncope = syn(short) + kope (to cut)
Definitions to Know
Palpitations - sensation of strong, rapid, or irregular heart beats
Syncope – transient loss of consciousness and postural tone due to generalized cerebral ischemia with rapid and spontaneous recovery
Presyncope - no complete loss of consciousness occurs
Syncope = syn(short) + kope (to cut)

4. Syncope in children Affects 15% of children between 8-18
Uncommon under age 7 therefore think about:
Seizure disorders
Breath holding
Primary cardiac dysrhythmias
Cardiovascular causes unusual but life-threatening
anatomic abnormalities
congenital malformations
valvular disease
electrical abnormalities

5. Syncope in children Vasovagal Events
32% to 50% of cases
Decreased PVR
Decreased venous return
Decreased cardiac output
Hypotension
Bradycardia
In teens – think about pregnancy and drugs of abuse

6. Syncope: Key questions to address with initial evaluation
Is the loss of consciousness attributable to syncope or not?
Is heart disease present or absent?
Are there important clinical features in the history that suggest the diagnosis?

7. Syncope Mimics Disorders without impairment of consciousness
Falls
Drop attacks
Cataplexy
Psychogenic pseudo-syncope
Transient ischemic attacks
Disorders with loss of consciousness
Metabolic disorders
Epilepsy
Intoxications
Vertebrobasilar transient ischemic attacks

8. Differential Diagnosis of Syncope: Seizures vs Hypotension
Observation
Seizure
Inadequate Perfusion
Onset
Sudden
More gradual
Duration
Minutes
Seconds
Jerks
Frequent
Rare
Headache
Frequent (after)
Occasional (before)
Confusion after
Incontinence
Eye deviation
Horizontal
Vertical (or none)
Tongue biting
Prodrome
Aura
Dizziness
EEG
Often abnormal
Usually normal

9. Unexplained Causes = Approximately 1/3
Causes of True Syncope
Neurally-
Mediated
Orthostatic
Cardiac
Arrhythmia
Structural
Cardio-
Pulmonary 1
Vasovagal
Carotid Sinus
• Situational
Cough
Post-
Micturition 2
Drug-Induced
• Autonomic Nervous System Failure
Primary
Secondary 3
Brady
SN Dysfunction
AV Block
• Tachy VT
SVT
Long QT Syndrome 4
Acute Myocardial Ischemia
Aortic Stenosis
HCM
Pulmonary Hypertension
Aortic Dissection
Unexplained Causes = Approximately 1/3

10. Likely Causes In Children
Vasovagal
Situational
Psychiatric
Long QT*
WPW syndrome
RV dysplasia
Hypertrophic cardiomyopathy
Catecholaminergic VT
Other genetic syndromes

11. Syncope: Key questions to address with initial evaluation
Is the loss of consciousness attributable to syncope or not?
Is heart disease present or absent?
Are there important clinical features in the history that suggest the diagnosis?

12. Syncope: Important Historical Features
Questions about circumstances just prior to attack
Position (supine, sitting , standing)
Activity (rest, change in posture, during or immediately after exercise, during or immediately after urination, defecation or swallowing)
Predisposing factors (crowded or warm place, prolonged standing post-prandial period) and of precipitating events (fear, intense pain, neck movements)
Questions about onset of the attack
Nausea, vomiting, feeling cold, sweating, pain in chest

13. Syncope: Important Historical Features
Questions about attack (eye witness)
Skin color (pallor, cyanotic)
Duration of loss of consciousness
Movements ( tonic-clonic, etc.)
Tongue biting
Questions about the end of the attack
Nausea, vomiting, diaphoresis, feeling cold, muscle aches, confusion, skin color, wounds

14. Syncope: Important Historical Feature
Questions about background
Number and duration of syncope spells
Family history of arrhythmic disease or sudden death
Presence of cardiac disease
Neurological disease
Medications (Hypotensive, negative chronotropic and antidepressant agents)

15. Clinical Features Suggesting Specific Cause of Syncope
Neurally-Mediated Syncope
Absence of cardiac disease
Long history of syncope
After sudden unexpected, unpleasant sensation
Prolonged standing in crowded, hot places
Nausea vomiting associated with syncope
During or after a meal
With head rotation or pressure on carotid sinus
After exertion

16. Clinical Features Suggesting Specific Cause of Syncope
Syncope due to orthostatic hypotension
After standing up
Temporal relationship to taking a medication that can cause hypotension
Prolonged standing
Presence of autonomic neuropathy
After exertion

17. Clinical Features Suggestion Cause of Syncope
Cardiac Syncope
Presence of structural heart disease
With exertion or supine
Preceded by palpitations
Family history of sudden death

18. Initial Exam: Thorough Physical
Vital signs
Heart rate
Orthostatic blood pressure change
Cardiovascular exam: Is heart disease present?
ECG: Long QT, pre-excitation, conduction system disease
Echo: LV function, valve status, HCM
Neurological exam
HCM—Hypertrophic Cardiomyopathy
Brignole M, Alboni P, Benditt D, et al. Guidelines on management (diagnosis and treatment) of syncope—Update Europace. 2004;6:

19. Orthostatic Measurements
Classically, abnormal if systolic BP decreases by more than 20 points and/or pulse increases in pulse rate of more than 20 beats per minute after a change from supine to standing
If there is only a pulse increase but no drop in blood pressure, the test is less significant.

20. Diagnostic Objectives
Distinguish true syncope from syncope mimics
Determine presence of heart disease and risk for sudden death
Establish the cause of syncope with sufficient certainty to:
Assess prognosis confidently
Initiate effective preventive treatment

21. “…cardiac syncope can be a harbinger of sudden death.”
Survival with and without syncope (adults and children)
6-month mortality rate of greater than 10%
Cardiac syncope doubled the risk of death
Includes cardiac arrhythmias
No Syncope
Vasovagal/other
Cardiac Cause
Follow-Up (yr)
Probability of Survival
1.0
0.8
0.6
0.4
0.2
0.0
Soteriades ES, et al. N Engl J Med. 2002;347:878.

22. Electrocardiogram yield for specific diagnosis low (5%)
risk free and relatively inexpensive
abnormalities (BBB, previous MI, nonsustained VT) guide further evaluation
recommended in almost all patients

23. Laboratory Tests Routine use not recommended
Maybe glucose?
Should be done only if specifically suggested by H&P
Pregnancy testing should be considered in women of child-bearing age

24. Neurologic Testing EEG - not useful unless seizures
Brain imaging - not useful unless focality
Neurovascular studies
no studies
may be useful if bruits, or hx suggests vertebrobasilar insufficiency

25. Final Words of Wisdom -Is it Syncope?-
History is key!!!!
Orthostatics
take the time to do them correctly
Cardiac vs Non-cardiac
If you are not confident that it is NOT cardiac  REFER
ECG
Use it if you got ‘em!