Syncope and Sudden Death

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Syncope and Sudden Death
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• Syncope usually benign, but may represent serious
  cardiac problems.
• Sudden death in peds d/t cardiac, neurologic,
  resp., and trauma.
• Syncope is very common in adolescence. Most
  common cause neurally mediated syncope.

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• Sudden unexpected death include seizure, asthma,
  or toxic ingestion.
• Sudden Cardiac death relates to cardiac
  dysfunction and is the most common cause of
  sports related deaths in children.
• Most commonly d/t hypertrophic cardiomyopathy.

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• Syncope-sudden falling with brief LOC. Most
  experience a prodrome of lightheadedness or
  dizziness.
• May have involuntary motor responses.
• Sudden cardiac death is usually unexpected and
  unwitnessed.

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• Risk factors for serious cause of syncope.
• Exertion preceding event
• Cardiac disease
• Family history of sudden death
• Recurrent episodes
• Recumbent episode
• Chest pain/palpitations
• On meds that alter cardiac conduction

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• Patients history and physical exam is important
  in identifying the cause of syncope.
• Syncope during exercise is ominous.
• Cardiac exam should include palpation of cardiac
  impulse, auscultation, eval of peripheral pulses.
• Orthostatics identify volume depletion.

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• Cardiovascular, neuro, and pulmonary exams are
  often normal.
• EKG is recommended for all pts.
• Atypical or worrisome presentation should have
  cardiac panel, cbc, bmp, thyroid panel, cxr,
  alcohol, UDS.

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• Neurally mediated syncope includes vasovagal,
  vasodepressor, neurocardiogenic, reflex syncope
  and simple fainting. Considered benign.
• NMS is the most common cause of syncope in
  children.
• Last lt1 min
• Due to prolonged standing, emotional upset, sight
  of blood, physcial exertion, etc.

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• Orhtostatic- lightheadedness and weakness with
  standing.
• Drop of 20 in SBP with increase of 20 BPM in HR.
• Situational-urination, defecation, coughing, and
  swallowing. Due to carotid sinus hypersensitivity
  or valsalva response.

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• Cardiac dysrhythmias only seen in 3 of
  pediatrics with syncope.
• Suspect if syncope occurs with fright, anger,
  surprise, or physical exertion.
• Long QT syndrome is associated with hypertrophic
  cardiomyopathy, postive family history, and
  medications (Macrolides, TCA, antifungals,
  antihistamines, Trimethoprim, Quinolone).
• If suspected, holter monitor should be placed.

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• Other cardiac dysrhythmias
• WPW
• AV block
• SSS
• SVT

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Structural Heart disease

• Hypertrophic Cardiomyopathy- syncope is common
  presentation. In infant may present with CHF and
  cyanosis.
• Dilated Cardiomyopathy
• If diagnosed before 14, 50 10 yr mortality rate.
• Congenital cyanotic and non-cyanotic disease.
• Valvular disease
• Pulmonary HTN

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Nonvascular causes

• Seizures-associated with immediate convulsions,
  onset while supine and, prolonged postictal
  phase.
• Breath holding-common in 6-18 month olds due to
  emotional upset
• Atypical migraine
• Hyperventilation
• Hysteria
• Hypoglycemia

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Treatment

• Child who survives cardiac arrest must be
  stabilized and PALS followed.
• Unstable rhythms-cardiovert
• Wide QRS tachydysrhythmias should not be treated
  with procainamide if LQTS is suspected. Use
  amiodarone instead.

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Disposition

• Admit pts with documented dysrhythmia.
• Admit those with high risk factors
• Treat any identified causes and admit.
• Normal EKG but suspicious for dysrhythmia may be
  able to follow up for ambulatory cardiac
  monitoring

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• Pts with sudden cardiac arrest who survive should
  be transferred by appropriate crew to the nearest
  PICU.