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  1. 1. Pediatric Emergency Medicine Core Education Module 2010 CMC Department of Emergency Medicine Division of Pediatric Emergency Medicine
  2. 2. Objectives At 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
  3. 3. What is Syncope? 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 it occurs in 15-50% of adolescents
  4. 4. 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
  5. 5. Beware the Mimics Seizures Migraines Hyperventilation Choking games Hysteria/conversion
  6. 6. Where to begin your evaluation? History! Warning signs! What was happening around Triggered by fright or sound the patient? No prodrome What did he/she feel Exertional like/sense before the event? Palpitations or chest pain What position was he/she in Brief posturing when it happened? Family history of sudden Did he/she have chest pain or cardiac death, known headache before/after? arrhythmia Try to get a witness! Congenital heart disease
  7. 7. Other questions to consider… More history Family history Menstrual history Early cardiac death <45y Medical problems Known arrhythmia Access to medications or Familial cardiomyopathy illicit drugs
  8. 8. Physical Exam Orthostatics 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 dysrhythmia Complete vitals including 4 extremity BP
  9. 9. Physical Exam Full physical exam with emphasis on: Detailed neurologic exam Cardiac exam  -Murmurs, rubs and gallops  -Signs of heart failure Document carefully and thoroughly
  10. 10. Testing Accu-check! especially if patient is not at mental baseline or event was recent ECG Urine pregnancy test Hemoglobin Urine drug screen (if still altered) No neurologic imaging is indicated unless persistent focal neurologic abnormality.
  11. 11. What Cardiac Diagnoses Are We Looking For?!? Plumbing Problems Electrical Problems Hypertrophic Long QT cardiomyopathy Brugada Anomolous coronary arteries Polymorphic VT Ventricular cardiomyopathy Congenital short QT Aortic stenosis Pre-excitation (Wolff- Pulmonary hypertension Parkinson-White syndrome) Acute myocarditis Dilated cardiomyopathy
  12. 12. 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
  13. 13. 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
  14. 14. 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.
  15. 15. 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
  16. 16. 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
  17. 17. High Yield Points If patient is at baseline, there is little need for extensive work-up Screening ECG, though low yield, will screen for most life threatening cardiac syncope Look for anemia, hypoglycemia Always check urine pregnancy test No indication for ED neuro-imaging in a child without focal neurologic sign
  18. 18. Interesting Articles Goble 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.
  19. 19. 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: