Pediatric Emergency Medicine Core Education Module 2010 CMC Department of Emergency Medicine Division of Pediatric Emergency Medicine
ObjectivesAt the end of this module you will be able to: Define syncope Discuss possible mimics of syncope Describe an appropriate emergency department evaluation of syncope Discuss high risk characteristics of patients with syncopal episodes
What is Syncope?Brief sudden loss of consciousness with loss of postural tone that resolves spontaneouslyPre-syncope refers to feeling faint without true loss of consciousnessLiterature reports it occurs in 15-50% of adolescents
What Causes Syncope In children and adolescents, the most common cause is vasovagal Our job is to rule out the life threatening causes Dysrhythmias (usually tachydysrhythmias) Cardiac outflow obstructions Toxic exposures Hypoglycemia Ectopic pregnancy
Beware the MimicsSeizuresMigrainesHyperventilationChoking gamesHysteria/conversion
Where to begin yourevaluation? History! Warning signs!What was happening around Triggered by fright or sound the patient? No prodromeWhat did he/she feel Exertional like/sense before the event? Palpitations or chest painWhat position was he/she in Brief posturing when it happened? Family history of suddenDid he/she have chest pain or cardiac death, known headache before/after? arrhythmiaTry to get a witness! Congenital heart disease
Other questions to consider…More history Family historyMenstrual history Early cardiac death <45yMedical problems Known arrhythmiaAccess to medications or Familial cardiomyopathy illicit drugs
Physical ExamOrthostatics Change from sitting to standing Decrease of SBP >20 or increase of HR> 20 More important than the numbers is ability to recreate symptoms Normal does not exclude cardiac dysrhythmiaComplete vitals including 4 extremity BP
Physical ExamFull physical exam with emphasis on: Detailed neurologic exam Cardiac exam -Murmurs, rubs and gallops -Signs of heart failureDocument carefully and thoroughly
TestingAccu-check! especially if patient is not at mental baseline or event was recentECGUrine pregnancy testHemoglobinUrine drug screen (if still altered)No neurologic imaging is indicated unless persistent focal neurologic abnormality.
Long QT Mattu, A and Brady, W. ECGs for the Emergency Physician 2. p 30.• Delayed repolarization• May be familial (ask about family history)• QTc = >460ms• Can cause syncope from ventricular dysrhythmia → Torsades de Pointes → ventricular fibrillation arrest• Treatment = beta blockers
Brugada Pattern Mattu, A and Brady, W. ECGs for the Emergency Physician 2. pg 126.• RBBB or incomplete RBBB pattern in V1-V2 with ST Elevation• At risk for monomorphic and polymorphic ventricular tachycardia• Need pacemakers
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 Mattu, A and Brady, W. ECGs for the Emergency Physician 2. pg 160.
Wolff-Parkinson-White Syndrome Mattu, A and Brady, W. ECGs for the Emergency Physician 2. pg 60. • Short PR interval and delta wave are diagnostic • Represent signal transmitting around the AV node through a 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 needs cardiology consultation / follow-up? Family history of sudden death or malignant arrhythmia Exercise related syncope Cardiac history If abnormal ECG, fax to cardiology for an interpretation prior to admitting patient
High Yield PointsIf patient is at baseline, there is little need for extensive work-upScreening ECG, though low yield, will screen for most life threatening cardiac syncopeLook for anemia, hypoglycemiaAlways check urine pregnancy testNo indication for ED neuro-imaging in a child without focal neurologic sign
Interesting ArticlesGoble MM, et al. ED management of pediatric syncope: searching for a rationale. American Journal of Emergency Medicine, 2008; 26: 66-70.Dovyalyuk J, et al. The electrocardiogram in the patient with syncope. American Journal of Emergency Medicine, 2007; 25(6): 688-701.
Please contact Sean M. Fox, MD with any questions or comments. Carolinas Medical Center Medical Education Building, 3rd Floor 1000 Blythe Blvd Charlotte, NC 28270 Office: (704) 355-7205 Email: email@example.com