Sean Mindra, MS3

Thursday July 30th, 2015

Syncope

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

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?

*Syncope

What? - Sudden, abrupt loss of consciousness and tone

Why? – transient decrease in global cerebral perfusion

**Complete spontaneous recovery!

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

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?

*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

"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?

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

*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

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

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?

Past Medical History:

*Previous episodes

*Other medical conditions?

*Seizures

*Cardiac abnormalities

*Insulin dependent diabetes

*Anaphylaxis

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?

Meds:

*Beta/calcium channel blockers

*Diuretics

*Vasodilators

*Medications that prolong QT

*Anti-depressants

*Neuroleptics

*Antibiotics

*Anti-arrythmics

*Zofran

Family History

*History of syncope?

*Pacemaker?

*Sudden cardiac death?

*Prolonged QT

*HOCM

*MI at a young age?

What’s next?

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

Lets Review our DDx:

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

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

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

*Which Investigations to Order?

*ECG*Bloodwork

*Glucose

*Holter monitor

*Stress testing

*EEG

*CT Head

*Tilt table testing

Investigations

Things to Consider:

Tilt Table Procedure

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)

*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)