Chest pain and syncope

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A basic talk for pediatricians on syncope and chest pain: how not to miss lifethreatening problems in children.

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Chest pain and syncope

  1. 1. April 22nd 2008: Amity SchoolClass VII student dies of cardiac arrestNew Delhi: A class VII student in Delhi collapsed on her schools football filed and died within minutes. The student had no history of heart trouble but doctors attending to her say she died of a cardiac arrest.12-year-old Surabhi Rajput collapsed after jogging around the football field of her school and died within 15 minutes of reaching the hospital."She was standing and talking to her friends when she suddenly collapsed, she was taken to the doctor.""These things are clinically detectable with a stethoscope one can hear any murmur and if required the paediatrician refers the patient to a cardiologist." PEDIATRIC CARDIOLOGY & CARDIAC SURGERY UNIT
  2. 2. • “If a person collapses from cardiac arrest, recovery is possible only by use of a defibrillator — which gives an electric shock to restart the heart or through Cardio Pulmonary Resuscitation.• Cardiologists suggest that learning CPR be made mandatory in all schools so that reviving a child who suffers from cardiac arrest are higher.• Also getting an echo test of your child to eliminate any structural defects, as well as an ECG. Its the first step to ensure your child has a healthy heart” PEDIATRIC CARDIOLOGY & CARDIAC SURGERY UNIT
  3. 3. SYNCOPE & SUDDEN CARDIAC DEATHDEPT OF PEDIATRIC CARDIOLOGY & CONGENITAL CARDIAC SURGERY INDRAPRASTHA APOLLO HOSPITAL NEW DELHI PEDIATRIC CARDIOLOGY & CARDIAC SURGERY UNIT
  4. 4. The difference in Syncope andDeath is that in one you wake up and in the other you dont 15% of all school going kids will have an episode of syncope PEDIATRIC CARDIOLOGY & CARDIAC SURGERY UNIT
  5. 5. TYPES OF SYNCOPE – CARDIAC – NON-CARDIAC (Neural & Psych) – NEUROCARDIOGENIC PEDIATRIC CARDIOLOGY & CARDIAC SURGERY UNIT
  6. 6. CARDIAC SYNCOPE • 15 yr boy playing football with racing heart: • Structural Heart Ds – HOCM – Aortic Stenosis – Rare Coronary Abn: Athletic Death • Cardiac Arrhythmia – WPW Syndrome, Long QT syndrome – AV Block;ARVD;Myocarditis PEDIATRIC CARDIOLOGY & CARDIAC SURGERY UNIT
  7. 7. Diagnoses linked to ECG findings• Myocardial infarction• Arrhythmia• Sinus arrhythmia is normal• PACs or PVCs may manifest as chest pain in younger child• Subtle P waves may indicate Junctional rhythm• Long QTc• ST – T changes• Myocarditis• Pericarditis• Hypertrophic cardiomyopathy PEDIATRIC CARDIOLOGY & CARDIAC SURGERY UNIT
  8. 8. BIGEMINY PEDIATRIC CARDIOLOGY & CARDIAC SURGERY UNIT
  9. 9. COUPLETS PEDIATRIC CARDIOLOGY & CARDIAC SURGERY UNIT
  10. 10. SALVOS PEDIATRIC CARDIOLOGY & CARDIAC SURGERY UNIT
  11. 11. ECGRule out long QT Syndrome PEDIATRIC CARDIOLOGY & CARDIAC SURGERY UNIT
  12. 12. EchoRule out Congenital Coronary Abnormaities PEDIATRIC CARDIOLOGY & CARDIAC SURGERY UNIT
  13. 13. Blood Work Up• CPK-MB Vs Troponin I – 3 to 6 hours after the onset of ischemia and may persist for 5 to 8 days.• Don’t forget Cocaine as an etiology and ask for Tox Screen ! PEDIATRIC CARDIOLOGY & CARDIAC SURGERY UNIT
  14. 14. In many children the exact cause of chest pain may not be elicited after initial work up. Follow Up may be the best route PEDIATRIC CARDIOLOGY & CARDIAC SURGERY UNIT
  15. 15. Syncope in childrenPEDIATRIC CARDIOLOGY & CARDIAC SURGERY UNIT
  16. 16. Case Scenarios• 12 yr old, long • 15 yr, athletic morning assembly • Exercises 1• Did not have hour/day breakfast • Plays in School• Summer hot sun Football team• FAINTS: • While running on• Felt heart beat field faints Increase • “Looked pale”• Black out- • Took “Long” to recovered fast recover PEDIATRIC CARDIOLOGY & CARDIAC SURGERY UNIT
  17. 17. TYPES OF SYNCOPE – CARDIAC – NON-CARDIAC (Neural & Psych) – NEUROCARDIOGENIC PEDIATRIC CARDIOLOGY & CARDIAC SURGERY UNIT
  18. 18. NON-CARDIAC SYNCOPE• Seizure disorder• Breath - Holding: 18 month child with temper tantrums• Migraine• Orthostatic hypotension• Situational:hair grooming, Micturitional, cough,neck hyperextensn,"burning hair"• Metabolic: hypoglycemia PEDIATRIC CARDIOLOGY & CARDIAC SURGERY UNIT
  19. 19. NEUROCARDIOGENIC SYNCOPE• THE MOST COMMON CAUSE OF SYNCOPE IN CHILDREN !!• Initiated by: – Provocation:fear,anxiety,pain,phlebotomy – Physical Stress:dehydratn,recent illness, crowded poorly ventilated, hunger, after exercise PEDIATRIC CARDIOLOGY & CARDIAC SURGERY UNIT
  20. 20. WORK-UP FOR SYNCOPE• History is very important • from pt & witness • what was the pt exactly doing-running or resting ? • What came first-chest sympt or dizziness ? • Was the heart pounding/palpitation or heart went very slow ? – Witness: • Duration of syncope? • Was the patient pale ? Sweaty ? Anyone tried feeling pulse ? Was it racing ? PEDIATRIC CARDIOLOGY & CARDIAC SURGERY UNIT
  21. 21. TILT TEST 110 110/75/60 PEDIATRIC CARDIOLOGY & CARDIAC SURGERY UNIT
  22. 22. RESPONSES TO TILT TESTPSYCHOGENIC DYSAUTONOMICNo change in HR, BP,TCD Gradual parallel TILT TEST NCS P.O.T.S. CEREBRAL PEDIATRIC CARDIOLOGY & CARDIAC SURGERY UNIT
  23. 23. TYPES OF NCS RESPONSE 3 types of NCSVasodepressor Mixed Cardio-inhibitory PEDIATRIC CARDIOLOGY & CARDIAC SURGERY UNIT
  24. 24. CARDIO-INHIBITORY NCS14012010080604020 0 PEDIATRIC CARDIOLOGY & CARDIAC SURGERY UNIT
  25. 25. VASODILATOR NCS14012010080604020 0 PEDIATRIC CARDIOLOGY & 1 2 3 4 5 6 7 8 9 CARDIAC SURGERY 16 17 18 10 11 12 13 14 15 UNIT 19 20 21 22 23 24 25 26 27
  26. 26. Neuro-Cardiac Syncope• Tilt Test rarely needed• Vaso-Dilatory most common• Increase Water & Salt Intake in children with typical VD – NCS• Warning: If the syncope is while exercising or with no postural change• Always rule out Long QTc• A common condition with normal heart & brain PEDIATRIC CARDIOLOGY & CARDIAC SURGERY UNIT
  27. 27. LONG QT SYNDROMEPEDIATRIC CARDIOLOGY & CARDIAC SURGERY UNIT
  28. 28. RRQTc = QT/√RR QT PEDIATRIC CARDIOLOGY & CARDIAC SURGERY UNIT
  29. 29. LONG QT SYNDR PEDIATRIC CARDIOLOGY & CARDIAC SURGERY UNIT
  30. 30. TYPES OF LONG QT PEDIATRIC CARDIOLOGY & CARDIAC SURGERY UNIT
  31. 31. ROMANO WARD SYNDROME ChromosLQTS Mutated omal Ion Current AffectedType Gene LocusLQT1 11p15.5 KVLQT1) Potassium current (IKs)LQT2 7q35-36 HERG Potassium current (IKr)LQT3 3p21-24 SCN5A Sodium current (INa)LQT4 4q25-27 ? ? KCNE1 21q22.1-2LQT5 (heterozy Potassium current (IKs) 2.2 gotes) 21q22.1-2 Potassium current (IKr)LQT6 MiRP1 2.2 PEDIATRIC CARDIOLOGY & CARDIAC SURGERY UNIT
  32. 32. Long QT Syndrome• 1 in 3000 incidence in population• Females > Males• Syncope• Arrhythmia induced by Sound, Cold water, exercise, emotion• Sodium channel blockers in LQT3, potassium supplementation with spironolactones in LQT2: Clinical trials PEDIATRIC CARDIOLOGY & CARDIAC SURGERY UNIT
  33. 33. PEDIATRIC CARDIOLOGY & CARDIAC SURGERY UNIT
  34. 34. Scoring System for LQTS PEDIATRIC CARDIOLOGY & CARDIAC SURGERY UNIT
  35. 35. SUDDEN CARDIAC DEATHPEDIATRIC CARDIOLOGY & CARDIAC SURGERY UNIT
  36. 36. Sudden Cardiac Death – Dilated cardiomyopathy • Genetic – Hypertrophic Arrhtythmia: cardiomyopathy – Arrhythmogenic right – Long QT syndrome ventricular dysplasia – Acquired long QT• Valvular disease syndrome – Aortic stenosis – Short QT – MVP Syndrome: • Ventricular tachyarrhythmias – Wolff-Parkinson-• Right ventricular White syndrome outflow tract – Brugada syndrome ventricular tachycardia – Catecholaminergic• Other polymorphic – Pulmonary embolism. ventricular – Aortic dissection tachycardia – VF PEDIATRIC CARDIOLOGY & CARDIAC SURGERY UNIT
  37. 37. What Causes SCD ? PEDIATRIC CARDIOLOGY & CARDIAC SURGERY UNIT
  38. 38. Incidence of Etiology1 in 500 people have Hypertrophic Cardiomyopathy (HCM)HCM is 7 times more common than Cystic FibrosisThere are often no warning signs or symptoms. Often the first sign of HCM is sudden deathLong QT Syndrome is 3 times more common than childhood leukemiaOn average, 1 young athlete dies every 3 days from sudden cardiac death PEDIATRIC CARDIOLOGY & CARDIAC SURGERY UNIT
  39. 39. Work up for Missed SCD ?• ECG• Echo: Pediatric Cardiologists – Please get the answer that Anomalous Coronary course has been ruled out• MRI – ARVD, Coronary Abn-further Definition• If needed Cath or EP or Biopsy PEDIATRIC CARDIOLOGY & CARDIAC SURGERY UNIT
  40. 40. PEDIATRIC CARDIOLOGY & CARDIAC SURGERY UNIT
  41. 41. PEDIATRIC CARDIOLOGY & CARDIAC SURGERY UNIT
  42. 42. PEDIATRIC CARDIOLOGY & CARDIAC SURGERY UNIT
  43. 43. CHEST PAIN IN KIDS & ADOLESCENTS OUTPATIENT/ER APPROACHPEDIATRIC CARDIOLOGY & CARDIAC SURGERY UNIT
  44. 44. Chest Pain in Children• not an unusual symptom in a child• in adults it refers to myocardial infarction• This is what causes anxiety in parents and prompts an ER visit or a visit to you PEDIATRIC CARDIOLOGY & CARDIAC SURGERY UNIT
  45. 45. Chest Pain in Children• serious or life threatening conditions presenting with chest pain are less common in kids• But they still cannot be overlooked• Cardiac etiology though less common may still carry a high risk• One may want to just rule out these dangerous conditions PEDIATRIC CARDIOLOGY & CARDIAC SURGERY UNIT
  46. 46. Cardiac diagnoses presenting as chest pain• Congenital defects – coronary arterial anomalies – aortic valvar and supravalvar stenosis• Abnormal Rhythm• Acquired diseases – pericarditis – autoimmune vasculitis – Kawasaki disease – drug abuse and medications: cocaine, methyphenidate – trauma – endocarditis – hyperlipidemia PEDIATRIC CARDIOLOGY & CARDIAC SURGERY UNIT
  47. 47. Facts About Chest Pain in Kids• In majority etiology cannot be found and is idiopathic (63%).• There is no gender preference amongst patients with this symptom.• Majority have localization to the left chest.• Psychiatric, Cardiac, GI, Pulmonary, and Musculoskeletal together constitute 35% of all patients. PEDIATRIC CARDIOLOGY & CARDIAC SURGERY UNIT
  48. 48. Indicators of etiology of chest painon history If chest pain increases with breathing Respiratory If chest pain is with exercise Cardiac/EIA If chest pain more on bending forward Pericardial If syncope/presyncope associated Cardiac Hx trauma-maybe subtle- Has to be elicited Hx of viral Costochondritis Chest pain maybe a misrepresentation Palpitation (SVT) Sudden-back-Marfans Aortic dissection Family Hx Marfans Pain after meals/spicy foodPEDIATRIC CARDIOLOGY & Gastrointestinal CARDIAC SURGERY UNIT
  49. 49. Indicators of Etiology onphysical exam• Tachycardia Rule out arrhythmia• Irregular heart beat Rule out myocarditis• Tachypnea Rule out respiratory• Tenderness Costochondritis• Breast tenderness-boys-adolescent Pubertal-physiologic• Bruise Trauma• Wheeze Asthma• Murmur Cardiac / MVP• Epigastric tenderness Gastrointestinal PEDIATRIC CARDIOLOGY & CARDIAC SURGERY UNIT
  50. 50. Chest x-ray findings to look for in children withchest pain• Congenital rib anomalies e.g. cervical rib, pectus, scoliosis• Rib fracture• Pleural fluid• Pneumonic patch• Cardiac enlargement• Chamber enlargement-heart ds• Non-specific: Pericardial Effussion• Pneumothorax-spontaneous• Pneumomediatinum-spontaneous PEDIATRIC CARDIOLOGY & CARDIAC SURGERY UNIT
  51. 51. YAHOO GROUP: PEDSCARDIOhttp://health.groups.yahoo.com/group/Pedscardio/ EDUCATIONAL WEBSITE FOR PEDIATRICIANS PEDIATRIC CARDIOLOGY & CARDIAC SURGERY UNIT

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