SYNCOPE IN PAEDIATRICS

1. SYNCOPE
IN
PEDIATRICS
Dr.Manoj
Prabhakar.M,
Resident (Dept of
Pediatrics)

2. 1)

3. 2)

4.  3) Mention three points of difference
between Syncope & Seizures
 4) Syncope is one of the typical
presentation in which heart disease.?

5. TOPICS DISCUSSED
 Definition of Syncope
 Seizure Vs Syncope
 Causes of Pediatric Syncope
 Red Flag Signs
 Evaluation
 Treatment

6. DEFINITION
Syncope:
 A transient loss of consciousness and
postural tone with spontaneous recovery
requiring no resuscitative efforts.
 It is symptom, not a diagnosis.

7. BRIEF INTRO
 Incidence : 5-20% in children below 15yrs.
 Majority of the episodes are benign and &
due to neurally mediated mechanism.
 Rarely caused by a potentially serious or life
threatening condition.
 History is the main tool in differentiating
benign from more serious causes of
syncope.

8. TRANSIENT LOSS OF CONSCIOUSNESS
Is it Seizure ?
Or
Syncope ?
If Syncope , is it Cardiac or Non Cardiac
Neurally
Mediated?
Psychogenic?
Metabolic?

9. SEIZURE VS SYNCOPE
SEIZURE SYNCOPE
Preceding Symptoms Aura , déjà Vu ,etc Dizziness
Position Occurs in any position Mainly standing,
Tongue Biting Frequently Present No
Urinary Incontinence Frequent Very rare
Stool Incontinence Rare Almost Never
Post Episode Prolonged confusion &
disorientation
Usually well oriented
within 1-2 mins

10. CAUSES OF PEDIATRIC SYNCOPE
- Neurologic
- Vasovagal syncope(pain, fear, Sight of
blood) Situational(cough, defecation,
micturition , swallowing….)
- Breath-holding spells

11. Cardiovascular
 Primary Electrical Disorders
- Tachyarrhythmia
- Bradyarrhythmia
- Long QT syndrome
CAUSES

12.  Outflow obstruction
Aortic stenosis
Hypertrophic obstructive cardiomyopathy
Pulmonary hypertension
Pulmonary stenosis
CAUSES

13.  Poor contractility
Congestive heart failure
Myocarditis
Dilated cardiomyopathy
CAUSES

14.  Orthostatic hypotension
- Hypovolemia(dehydration)
- Adrenal Insufficiency
Other
Anemia
Hypoglycemia
Medication ingestions
Conversion disorder
CAUSES

15.  Neurologic or Metabolic
- Neurological Events – Seizure Disorder
- Metabolic :
- Hypoglycemia
- Carbon Monoxide Poisoning
CAUSES

16. BEWARE WITH THE MIMICS
 Seizures
 Migraines
 Hyperventilation
 Choking games
 Hysteria/conversion

17. HISTORY SUGGESTIVE OF CARDIAC DISEASE
 Prior personal history of fatigue, exercise
intolerance, known arrhythmia or heart
disease.
 Syncope preceded by palpitations or chest
pain.
 Syncope during exercise.
 Syncope without prodrome.

18. CARDIAC SYNCOPE
Syncope which occurs due to a disorder within the
cardiac system
 Account for 2‐6% of syncope events
-- Structural Abnormality
Hypertrophic Cardiomyopathy (HCM)
-- Arrhythmia
Long QT Syndrome (Long QTS)

19. Long QT syndrome

20. Wolff-Parkinson-White syndrome. There are delta waves
(slurring of R wave) and short PR interval

21. Atrial fibrillation with rapid ventricular conduction

22. Presence of right bundle branch block pattern with ST elevation
in right chest leads (V1 and V2),
suggestive of Brugada syndrome

23. NEUROCARDIOGENIC SYNCOPE
 Precipitating Conditions :
- Prolonged Standing in a crowded place.
- Large Meal in a warm restaurant.
- Hot Shower.
- Most common cause in children and
adolescents
- Family history usually positive,

24. CONT..

25.  Prodromal Symptoms :
- Dizziness
- Nausea
- Lethargy
- Narrow vision
- Abdominal Discomfort.

26. NON‐CARDIAC SYNCOPE
Events which occur that are not related to
disorders of the heart and episode does not
present like a vasovagal syncope.
 Seizure
 Hypoglycemia
 Migraine Syndrome
 Hysteria
 Hyperventilation
 Choking

27. HITORY
 Important aspects of the history include:
a) Precipitating events, for example:
 Did it occur during physical activity (more concerning for
cardiac aetiology)
 Did it occur during long periods of standing (more
consistent with vasovagal)
 Is it recurrent?
 Any triggers or stressors?
b) Description of the episode itself, for example:
 Symptoms of dizziness, visual changes, nausea
(vasovagal)
 Abnormal movements (may be indicative of seizure activity)

28. CONTD..
c) Medical history;
i. A past history of cardiac conditions should immediately
increase your concern for cardiac cause of syncope.
ii. Medications
d) Family history:
Sudden death, known arrhythmias, cardiomyopathies

29. RED FLAG WARNINGS
 Scenario not typical for a simple
faint
 Syncope associated with chest
pain
 Syncope occurred during
exercise
 Syncope associated with
palpitations
 Prolonged loss of consciousness
 Abnormal physical examination
 Positive family history

30. SYNCOPE PRIMARY WORKUP
 Detailed personal and family history
 HR and BP monitoring
 Cardiac Auscultations in the supine and
standing positions.
 ECG.

31. OTHER EVALUATION
 Non‐Invasive Testing
Echocardiogram
Holter Monitor
Event Monitor
Stress Test
Laboratory testing/Genetic testing
• Invasive Testing
Electrophysiology (EP) Testing

32. HOLTER MONITOR
 24‐48 hr.
continuous
monitoring
 Wear
home/school
 Data
downloaded for
interpretation

33. EVENT MONITOR
 30 day continuous
monitoring
 Okay to remove for
brief periods
 Encourage routine
activity

34. TREATMENT
** Goal: Treat underlining cause of
syncope*
 Vasovagal Syncope
Eliminate triggers as much as possible
Increase fluid intake
Increase salt intake
(unless medically contraindicated)

35. Cardiac Syncope
 Surgery
 Ablation
 Medication
 Pacemaker
 Automated Implantable Cardioverter
Defibrillator (AICD)

37. CONCLUSION
 Syncope is categorized into 3 different types:
vasovagal, cardiac, and non cardiac.
 Mostly syncope is benign
 Can be a sign of a serious underlining cardiac
disease.
 Red flag warnings prompt further investigation.
 Further tests can help rule out cardiac disease
 Goal is to treat underlining cause of the syncope
 Prevent reoccurrence of syncope and/or sudden
cardiac arrest and even sudden cardiac death.

38. THANK YOU