sean mindra, ms3 thursday july 30 th, 2015. * define syncope and review the pathophysiology and...
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Sean Mindra, MS3
Thursday July 30th, 2015
Syncope
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Objectives
*Define syncope and review the pathophysiology and clinical manifestations
*Review the differential diagnosis for syncope
*Review the initial work-up and management of syncope, recognizing factors which would point to a life-threatening cause of syncope
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Case:ID: Tim, 14 y.o. M
Reason for visit: loss of consciousness at school a few days ago
HR: 72 bpm
BP: 122/68
RR: 16
What is syncope and why does it occur?
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*Syncope
What? - Sudden, abrupt loss of consciousness and tone
Why? – transient decrease in global cerebral perfusion
**Complete spontaneous recovery!
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Why learn about syncope?
*Quite common – approx. 1 out of 5 pediatric patients will experience a syncopal episode before 15 years of age
*It is scary (for both patients and the parents)! – thus, very high likelihood for patients to seek medical attention following an episode
*Most are benign….but our job is to learn about the more sinister causes and recognize them
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Back to the case…
ID: Tim, 14 y.o. M
Reason for visit: loss of consciousness at school a few days ago
*What sorts of causes are we thinking about as we enter the examination room?
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*DDx for Syncope:*Neurally-mediated syncope/NMS/ “vaso-vagal” =
BENIGN!
*Cardiovascularly mediated syncope
*Arrythmia vs. structural
*Non-cardiac pseudosyncope
*Epilepsy/seizures vs. psychogenic
*Drug/toxin induced
*Anaphylaxis
*Metabolic
*Mechanical fall
*Narcolepsy
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"Listen to your patient, he is telling you the
diagnosis,"*In cases of suspected syncope, the
medical history is of paramount importance
*Physical examination and initial investigations will generally add very little to the picture
*With that in mind, what sorts of questions to you want to ask Tim?
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History of Presenting Illness:
*What were you doing at the time? Leading up to event?
*Were you alone? Was it witnessed?
*Prodromal symptoms?
*Injuries?
*Jerky movements? Post-ictal state?
*Persisting neurologic deficits?
*Incontinence?
*Previous episodes/frequency of episodes
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*RED FLAG FEATURES
*History of heart murmur or congenital heart disease
*Syncope during exercise/exertion
*Family history of sudden cardiac death, long QT syndrome, heart disease
*Long-lasting syncope
*Unusual syncope triggers
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Tim:*I was at band practice, standing up for about 20
minutes
*I began to feel warm, dizzy, and mildly nauseated
*I then lost consciousness – my bandmates tell me I fell to the floor and was out for about 30 seconds
*They told me I was “very pale and clammy”, so I had a glass of water
*I felt pretty good after that but my teacher called my parents and I went home
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Tim:
*I did not feel my heart pounding or racing
*I did not feel short of breath
*No chest pain or discomfort before or after the episode…I just wanted to continue with band practice
What would we like to know about Tim’s past medical history?
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Past Medical History:
*Previous episodes
*Other medical conditions?
*Seizures
*Cardiac abnormalities
*Insulin dependent diabetes
*Anaphylaxis
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Tim’s Parents Say:
*Tim had one other episode where he lost consciousness
*This occurred about 1 year ago
*He was getting bloodwork at the time and looked quite pale
*Tim said that he felt quite hot and dizzy before passing out for a few seconds in the blood lab
*He returned to a normal state within a few minutes of regaining consciousness
Is Tim currently on any medications?
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Meds:
*Beta/calcium channel blockers
*Diuretics
*Vasodilators
*Medications that prolong QT
*Anti-depressants
*Neuroleptics
*Antibiotics
*Anti-arrythmics
*Zofran
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Family History
*History of syncope?
*Pacemaker?
*Sudden cardiac death?
*Prolonged QT
*HOCM
*MI at a young age?
What’s next?
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Physical Examination
HR: 72 bpm, BP: 122/68, RR: 16
Height: 165cm (50%ile), Weight: 44.7kg (25%ile)
Cardiac: Mild pectus excavatum. No heaves or thrills. Normal S1 and normally split S2. 1-2/6 systolic murmur at LLSB that disappeared with upright positioning. JVP normal. Femoral pulses easily palpable with no brachiofemoral delay.
Abdo: WNL.
Neuro: Non-contributory
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Lets Review our DDx:
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NMS
*Most common (60-80%)
*Often has many triggers (blood, needles, etc.)
*Prodrome
*No post-ictal period but can feel tired, warm, and clammy afterwards
*Positive family history of fainting
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Cardiac-mediated Syncope
*Abrupt onset
*Absence of usual prodromal symptoms or precipitating factors
*Unusual syncope triggers (i.e. loud noises)
*Is there a history of congenital heart disease
*Family history of sudden cardiac death
****Typically, EXERTIONAL in nature
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Pseudo-syncope*Epilepsy vs. psychogenic
*Epilepsy
*Tonic clonic movements
*Tongue biting
* Incontinence
*Post-ictal period
*Psychogenic
*Conscious or unconscious avoidance of unpleasant emotional situation
*Frequent episodes
*Prolonged events (can be hours)
*Almost never leads to injury
*Can experience syncope in supine position
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*Which Investigations to Order?
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*ECG*Bloodwork
*Glucose
*Holter monitor
*Stress testing
*EEG
*CT Head
*Tilt table testing
Investigations
Things to Consider:
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Tilt Table Procedure
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Management
*Reassurance! (Mainstay of therapy for NMS b/c not caused by epilepsy or a life-threatening cardiac cause)
*Education
*Recurrent episodes are common but most cases resolve within 5 years
*Avoid triggers
*Volume expansion for NMS (increasing salt and water intake)
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*For frequent, recurrent episodes refractory to conservative therapy…
*Medications/pharmacotherapy
*Depends on etiology/cause
*Options include:
*Beta blockers (Atenolol or metoprolol – mimics increased parasympathetic tone to prevent vagal output)
*Alpha agonists (stimulate HR and increase peripheral resistance)
*Mineralocorticoids (e.g. Florinef) for volume expansion (used along with salt/water intake)
*SSRI’s (has been described for refractory syncope)