Syncope in Children

Method of Participation: To earn AMA PRA Category 1 Credit™

Read the rules and terms of use below
Read the educational objectives and article "Syncope in Children" in print from the January 2013 issue of Emergency Physicians Monthly. You may also read the article online once you have read the rules and terms of use.
Complete the post-test and evaluation (Note: A score of at least 80% must be achieved to earn CME credit)
Participate in the discussion/debate thread about specific articles
Process your online payment of $10 (fees are non-refundable).
A certificate of attendance will be forwarded within 4 to 6 weeks of participation

Step One: Rules and Terms of Use

Release Date: January 15, 2013

Expiration Date: January 15, 2014

Estimated Time of Completion: 1 hour
Fee: This CME activity costs $10, payable by credit card at the completion of the activity. Fees are non-refundable.

CME Accreditation:
The Center for Emergency Medical Education (CEME) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Center for Emergency Medical Education (CEME) designates this educational activity for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Target Audience:
This activity is designed for emergency medicine physicians and other health care providers interested in the treatment of patients with cardiopulmonary arrest.

Description:
The Center for Emergency Medical Education (CEME) offers a one-credit content-specific posttest and evaluation based on an article in the Emergency Physicians Monthly magazine as each issue is published.

Disclosure of Faculty Financial Interests or Relationships:
It is the policy of Center for Emergency Medical Education (CEME) to insure balance, independence, objectivity, and scientific rigor in all its sponsored educational activities, and that all contributors present information in an objective, unbiased manner without endorsement or criticism of specific products or services and that the relationships that contributors disclose will not influence their contributions. In accordance with the Standards for Commercial Support issued by the Accreditation Council for Continuing Medical Education (ACCME), the Center for Emergency Medical Education (CEME) requires resolution of all faculty conflicts of interest to ensure CME activities are free of commercial bias. Those involved in the planning and teaching of this activity are required to disclose to the audience any relevant financial interest or other relationship.

All faculty, planners, and staff in a position to control the content of this CME activity have indicated that he/she has no relationship, which, in the context of the article, could be perceived as a potential conflict of interest:

Kevin M. Klauer, DO, FACEP, Director, CEME
Logan Plaster, Editor/Creative Director, Emergency Physicians Monthly
Ginger Brake, CEME Program Coordinator

System Requirements:
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Contact Information
Ginger Brake
CEME Program Coordinator
Emergency Medicine Physicians
4535 Dressler Road NW
Canton, Ohio 44718
(330) 493-4443 Ext: 1445
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The materials on this site are provided for general medical education purposes only and are not meant to be applied rigidly and followed in all cases. Use of this information in a particular situation remains the professional responsibility of the practitioner. In no event will CEME be liable for any decision made or action taken in reliance upon the information provided.

STEP 2: READ THE ARTICLE

STEP 3: TAKE THE QUIZ

STEP 4: PROCESS PAYMENT

Educational Objectives:
After evaluating this article, participants will be able to:
1. Incorporate into clinical practice critical questions that should be asked when taking the history of a child who experienced syncope
2. Recognize key symptoms associated with pediatric syncope
3. Develop strategies to identify illnesses associated with syncope

While most syncopal events in children are benign, there are certainly serious syncope conditions which exist, mainly involving the cardiovascular system. Fifteen to 20 percent of children will have one episode with neurogenic syncope being the overall most common cause. The physical examination is normal in up to 96% of children.

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Q. Are there any symptoms that can serve as a warning to providers when evaluating children who present with syncope?

A. In this study 72 percent of sudden cardiac arrest (SCA) victims were reported by their parents to have at least one cardiovascular symptom before SCA. The two most common symptoms were fatigue (44%) and near-syncope/lightheadedness (30%).

Citation: Drezner JA, Fudge J, Harmon KG etal. Warning symptoms and family history in children and young adults with sudden cardiac arrest. J Am Board Fam Med. 2012 Jul;25(4):408-15.

BACKGROUND: Children and young adults with undiagnosed cardiovascular disorders at risk for sudden death may have warning symptoms or significant family history that is detectable through screening. The objective of this study was to determine the prevalence of warning symptoms and family history in a cohort of children and young adults who suffered sudden cardiac arrest (SCA).

METHODS: A retrospective survey investigating warning symptoms and family history of cardiovascular disease was completed by families with a child or young adult who suffered SCA.

RESULTS: Eighty-seven of 146 families (60%) returned a completed survey. The SCA victims were an average age of 16 years (range, <5-29 years), 69% male, and 68% white. Seventy-two percent of SCA victims were reported by their parents to have at least one cardiovascular symptom before SCA, with fatigue (44%) and near-syncope/lightheadedness (30%) the two most common. Twenty-four percent of SCA victims had one or more (average 2.6; range, 1 to 10) events of syncope or unexplained seizure that remained undiagnosed as a cardiac disorder before SCA. Parents reported that cardiovascular symptoms first occurred, on average, 30 months (range, 19 to 71 months) before SCA; a symptom was brought to the attention of the child’s physician in 41% of cases. Twenty-seven percent of families reported a family member had suffered sudden death before age 50 because of a heart condition.

CONCLUSIONS: Many children and young adults who suffered SCA are reported to have cardiac symptoms or a family history of premature cardiac death. Syncope and unexplained seizure activity are distinct events but often go unrecognized as ominous signs of underlying cardiovascular disease. Physician education and increased public awareness regarding cardiovascular warning signs in the young may improve early detection of those at risk and prevent tragedies

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Q. Are there any questions that should be asked when taking the history of a child who presents with syncope?

A. The presence of any prodromal symptoms may be an important differentiator between cardiac and non-cardiac syncope. Syncope during exercise is an ominous sign whereas patients with syncope following prolonged standing, being in a warm, crowded place or emotional concerns such as fear of pain are more likely to have non-cardiac syncope.

Citation: Zhang Q, Zhu L, Wang C etal. Value of history taking in children and adolescents with cardiac syncope. Cardiol Young. 2012 Mar 15:1-7. [Epub ahead of print]

OBJECTIVES: This study was designed to investigate the value of history taking in identifying children with cardiac syncope, and to improve diagnostic efficiency and accuracy in children with cardiac syncope.

METHODS: The characteristics of a group of children and adolescents with cardiac syncope at the Pediatric Syncope Unit of five hospitals in China were compared with those with typical vasovagal syncope. 275 patients in Pediatric Syncope Unit were included.

RESULTS: A cardiac cause of syncope was established in 31 patients, autonomic-mediated reflex syncope in 214, non-syncopal attacks in 15, and in the remaining 15 the cause of syncope remained unexplained. Cardiac syncope was triggered by exercise, whereas vasovagal syncope by prolonged standing, warm-crowded place, and fear or pain emotion. Syncopal spells occurred at various positions in cardiac syncope. Children who had prodromal symptoms with cardiac syncope were significantly fewer than those with vasovagal syncope. Most children with cardiac syncope had history of abnormal electrocardiogram findings when compared with children suffering from vasovagal syncope. On multivariable analysis, history of abnormal electrocardiogram findings and exercise-triggered syncope were independent predictors of cardiac syncope.

CONCLUSION: Children and adolescents with a history of abnormal electrocardiogram findings and exercise-related syncope spells were at high risk for cardiac syncope.

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Q. Are there any common illnesses that predispose children to syncope?

A. This study revealed that children with febrile illnesses can present with a chief complaint of syncope. Approximately 25% of febrile patients in this trial had orthostatic hypotension when compared to only 5% in the non-febrile comparison group.

Citation: Shalem T, Goldman M, Breitbart R etal. Orthostatic Hypotension in Children with Acute Febrile Illness. J Emerg Med. 2012 May 10. [Epub ahead of print]

BACKGROUND: Children presenting to the Pediatric Emergency Department (PED) with fever often describe symptoms such as lightheadedness, dizziness, fatigue, and weakness, and may appear pale. They may also present with a chief complaint of syncope. Such symptoms may result from orthostatic hypotension.

OBJECTIVE: To determine whether children with an acute febrile illness have a higher incidence of orthostatic hypotension compared to afebrile children.

METHODS: A prospective cohort study was conducted at the PED at Assaf Harofeh Medical Center, a university-affiliated hospital in Israel. Eighty children aged 4-18 years were recruited. Thirty-nine had fever (>38°C for 6-48h) and 41 were afebrile. All subjects had their blood pressure measured in the supine position (after 5min of rest) and again after standing for 3min. The main outcome measure was orthostatic hypotension, that is, a reduction of systolic blood pressure of at least 20mm Hg, or a fall in diastolic blood pressure of at least 10mm Hg within 3min of standing.

RESULTS: There were no differences between the groups in gender, age, height, or weight. Orthostatic hypotension was found in 10/39 (25.6%) of febrile children and in 2/41 (5%) of afebrile children (p=0.012).

CONCLUSIONS: The incidence of orthostatic hypotension among febrile children in the PED is high, and may explain common symptoms such as dizziness or syncope. Such patients should be instructed to drink properly and to avoid rapid changes in body posture.

Summary

While most cases of syncope in children are benign, it is imperative to keep some key diagnoses in mind when evaluating these patients. Hypertropic cardiomyopathy is a common cause of sudden cardiac arrest. ECG findings may reveal small, deep Q wave (< 40 msecs) in the inferior and lateral leads along with high voltage. The murmur is accentuated by Valsalva maneuvers and standing. Check for a prolonged QT interval as these patients are at risk for ventricular arrhythmias such as torsades de pointes. Syncope during exercise is an important indicator of a cardiac cause. Febrile children may be more prone to orthostatic hypotension due to insensible fluid losses and therefore attention to hydration should be an integral aspect of care.

Dr. Ghazala Sharieff is the Director of Pediatric Emergency Medicine. Palomar Health, San Diego, CA, and a Clinical Professor, University of California, San Diego

STEP 3: TAKE THE QUIZ

STEP 4: PROCESS PAYMENT