4.10 Syncope

Question 1

Are most cases of childhood syncope serious

Answer 1

no- typically benign

Question 2

If someone faints once are they likely to faint at another time in their life

Answer 2

yes

Question 3

What is syncope

Answer 3

transient loss of consciousness due to a decrease in cerebral blood flow

• recovery is relatively prompt

Arousal after fainting within 1 to 2 minutes; recovery to full baseline state may have taken more than 1 hour
(many patients, though awake and alert, may not totally feel “like themselves” for a while)

Question 4

table 38.10

Question 5

What are the 2 main types of syncope

Answer 5

cardiac origin
noncardiac syncope (aka neurocardiogenic syncope, simple fainting)

Question 6

How does simple fainting occur

Answer 6

neurally mediated- systemic vasodilation + vagal bradicardia + hypotension lead to decreased cerebral flow and fainting

Question 7

Most syncope is ___ or ___

Answer 7

vasodepressive or vasovagal

Question 8

Is simple fainting more common in males or females

Answer 8

females

Question 9

During what situations is it common for toddlers to faint

Answer 9

breath holding spells

Question 10

When are breath holding spells most common

Answer 10

6 months-3 years old

Many of these cases resolve by 5 years old and the majority by 8 years old (after this time, they are usually classified as convulsive syncope)

Question 11

FYI

Stiffening, jerking motions during unconsciousness (tonic-clonic
muscular contractions of face [including fixed upward deviation of eyes], trunk, and extremities mimicking epilepsy occurs in approx-
imately half of individuals experiencing a syncopal episode)

Question 12

A patient presenting for syncope with a history of associated presyncopal symptoms with exercise should be investigated for what type of syncope

Answer 12

cardiac

aother red flags for cardiac syncope include: abnormal ECG, family history of arrhythmia, or abnormal physical examination.

Question 13

If you suspect a child of having cardiac syncope what should be done pending peds cardiology referral

Answer 13

restriction from sports participation

Question 14

What is key in the treatment of neurally mediated syncope

Answer 14

edication- cause, prevention, how to abort syncopal episode

Question 15

What are ways parents can be educated in preventing neurally mediated syncopal episodes

Answer 15

• hydration (includes decreasing caffeine and increasing sodium intake)
• using antigravity techniques at first sign of presyncopal sensations (isometric leg or arm contractions; squatting or lying down; possibly using compression socks).

isometric exercise is any type of exercise that holds the body in one position. The muscles are contracted but do not change length as you hold the position

Question 16

How should the patient be positioned if prodromal symptoms occur or after fainting

Answer 16

rest for 5-10 minutes supine or with legs up

Question 17

If syncopal episodes are linked to psychogenic factors what therapy should be sought

Answer 17

CBT

Psychogenic means something originates in the mind or is caused by psychological or emotional factors

Question 18

FYI

Physical Examination
A detailed neurologic examination is needed if the syncopal episode suggests a seizure disorder.
A cardiovascular examination is
especially important. In most cases the physical examination is completely normal.

Diagnostic Studies
The majority of individuals with cardiac syncope are identified either by a history of associated presyncopal symptoms with exercise, abnormal ECG, family history of arrhythmia, or abnormal
physical examination.
The diagnosis of neurally mediated syncope can confidently be made based on history, normal examination, and normal ECG.
The diagnostic work-up to distinguish between the two consists of:

• Orthostatic vital signs: More than a 30 mm Hg drop in BP after standing for 5 to 10 minutes, or a baseline systolic pressure of less than 80 mm Hg in an adolescent.
• Hemoglobin, if anemia is suspected: CBC, random glucose, and glucose tolerance tests have low yields and are not recommended routine tests for syncope.
• 12-lead ECG (looking for LVH, Wolff-Parkinson-White syndrome, AV and interventricular conduction defects, electrical myopathies [e.g., long QT syndrome]):

If ECG results are borderline or family history is highly suggestive of cardiac etiology, ECGs on siblings and parents may be useful.

Twenty-four-hour Holter monitoring and portable 30-day event monitoring can
also be beneficial.

• Echocardiography: Can be useful when history, physical, ECG, or family history suggests cardiac disease or cardiac syncope.
• Tilt table testing is not recommended for use in primary care due to poor reliability.
• Treadmill exercise testing may be used in cases of exercise-related syncope.