PediatricMorningReportPediatricMorningReportJuly20,2009July20,2009

ClaudiaClaudiaAlgazeAlgaze

ObjectivesObjectives

PresentacaseofsyncopePresentacaseofsyncopeFacilitatediscussionofcausesofFacilitatediscussionofcausesofsyncopesyncopePresentationofthecauseofsyncopePresentationofthecauseofsyncopeinourpatientinourpatientTakehomepointsTakehomepoints

RelevanceRelevance

CommonpresentationtopediatricCommonpresentationtopediatricclinincsclinincsandemergencydepartmentsandemergencydepartments

CanbeasymptomoflifethreateningCanbeasymptomoflifethreateningillnessillness

HighlightadiagnosisthatmayHighlightadiagnosisthatmayfrequentlybemissedfrequentlybemissed

CaseReportCaseReport

9yearoldfemalepresentsto9yearoldfemalepresentstopediatricEDafteranepisodeofpediatricEDafteranepisodeofsyncope.syncope.Priortothisshehashad4episodesPriortothisshehashad4episodesofpreofpresyncopeinthelast1syncopeinthelast12months2monthsNoothersignificantpastmedicalNoothersignificantpastmedicalhistoryhistoryShetakesnomedicationsShetakesnomedications

CaseReportContinuedCaseReportContinued

DescribesfeelingdizzyandthenDescribesfeelingdizzyandthenfeelingasshefeelingassheisgoingtopassoutisgoingtopassoutShefeelsnauseousanddevelopsaShefeelsnauseousanddevelopsaheadacheduringeventsheadacheduringeventsPrePresyncopalsyncopalepisodeshaveoccurredepisodeshaveoccurredwhilesittingatherdeskinherroomwhilesittingatherdeskinherroom

CaseReportContinuedCaseReportContinued

EpisodeofsyncopeoccurredoneEpisodeofsyncopeoccurredonehourpriortopresentationwhileshehourpriortopresentationwhileshewasrunningplayingaroundwithwasrunningplayingaroundwithfriendsoutsideofherhomefriendsoutsideofherhomeNonoticeablepalpitationsNonoticeablepalpitationsNofamilyhistoryofsyncope,suddenNofamilyhistoryofsyncope,suddencardiacdeath,congenitalheartcardiacdeath,congenitalheartdisease,orseizuresdisease,orseizures

InitialEvaluationInitialEvaluation

Temp36.5Temp36.5C,HR110,RR35,100%C,HR110,RR35,100%O2,BP110/75,O2,BP110/75,orthostaticsorthostaticsnormalnormalCompletephysicalexaminationrevealsCompletephysicalexaminationrevealssomewhatpaleandtiredappearingsomewhatpaleandtiredappearingchild,withmildtachycardiaandchild,withmildtachycardiaandtachypneatachypneaPhysicalexaminationisotherwisePhysicalexaminationisotherwisenormalnormal

WhatdiagnosesareyouconsideringWhatdiagnosesareyouconsideringatthistime?atthistime?

DefinitionofSyncopeDefinitionofSyncope

Syncope=transientlossofconsciousnessSyncope=transientlossofconsciousness&muscletonemostoftendueto&muscletonemostoftenduetoinadequatecerebralperfusioninadequatecerebralperfusion

PrePresyncope=thefeelingthatoneissyncope=thefeelingthatoneisabouttopassoutabouttopassoutbutnolossofbutnolossofconsciousnessconsciousness

HowCommonIsIt?HowCommonIsIt?

VariouscaseseriesestimatethatVariouscaseseriesestimatethat15%ofchildrenwillhavesyncope15%ofchildrenwillhavesyncopeAmongchildrenandadolescents,Amongchildrenandadolescents,mostcommonlyoccursin15mostcommonlyoccursin1519year19yearoldsoldsRepresents3%ofpediatricEDvisitsRepresents3%ofpediatricEDvisits

CausesofSyncopeCausesofSyncope

NeurocardiogenicNeurocardiogenicNeurologicNeurologicCardiacCardiacPsychogenic/Psychogenic/BreathHoldingBreathHoldingIntoxicationIntoxication

MetabolicMetabolic(Hypoglycemia)(Hypoglycemia)ObstructiveObstructiveRespiratoryRespiratoryDiseaseDiseaseSituationalSituational

RedFlagsRedFlags

KnownheartKnownheartdiseasediseaseRecurrenteventsRecurrenteventsSuddenfaintingSuddenfainting(no(noprodromeprodrome))FaintingduringFaintingduringexerciseexerciseKnowningestionorKnowningestionorexposureexposure

Abnormalrhythm/Abnormalrhythm/palpitationspalpitationsInjuryduringeventInjuryduringeventAbnormalrhythm/Abnormalrhythm/palpitationspalpitationsNeurologicNeurologicsignsorsignsorsymptomssymptoms

BackToOurPatientBackToOurPatient

ComplainsofheadacheandacuteComplainsofheadacheandacutechesttightnesschesttightnessEKGrevealsSTsegmentelevationinEKGrevealsSTsegmentelevationinanteriorandlateralleadsanteriorandlateralleadsCXRisnormalCXRisnormalInitialABGisnormal,InitialABGisnormal,lyteslytesnormalnormalCKCKMBis80U/LTIis15MBis80U/LTIis15ngng/ml/ml

BackToOurPatientBackToOurPatient

ThepatientThepatientsmotherrecallsshehasalsosmotherrecallsshehasalsobeenhavingheadacheslatelybeenhavingheadacheslately..

ABGwithcoABGwithcooximetryoximetryforevaluationbyforevaluationbygaschromatographyisperformedgaschromatographyisperformed

CarbonMonoxidePoisoningCarbonMonoxidePoisoning

www.homepage.montana.edu/.../18AirPollution.ppt

SomeFactsSomeFacts

FormedbyhydrocarboncombustionFormedbyhydrocarboncombustionNormalNormalCOHbCOHbinbloodis1inbloodis12%(metabolism,2%(metabolism,ambient)ambient)Odorless,tasteless,colorless,nonOdorless,tasteless,colorless,nonirritantirritantOneoftheleadingcausesofpoisoningdeathOneoftheleadingcausesofpoisoningdeathintheUnitedStatesintheUnitedStatesInadvertentcasesofpoisoningmostlybyInadvertentcasesofpoisoningmostlybysmokeinhalationsmokeinhalation

Kao,etal.2004

handyman247.ie/carbonmonoxide.html

PathophysiologyPathophysiology

www.empowher.com/.../carbonmonoxidepoisoning www.cyberounds.com/cmecontent/art332.html

DegreeofCOHbisafactorofrelativeamountsofCOandO2inenvironment,durationofexposure,andminuteventilation

www.lambtonfireservices.com/

Nonspecificsignsandsymptomsmayleadtomisdiagnosis

Kao,etal.2004andMartin,etal2000

MyocardialInjuryMyocardialInjury

EarlyeffectsfromresponsetohypoxiaEarlyeffectsfromresponsetohypoxiaHypotension,Hypotension,dysrhythmiadysrhythmia,ischemia,or,ischemia,orinfarctioninsignificantexposureinfarctioninsignificantexposureSeriesshowed37%ofpatientsshowingSeriesshowed37%ofpatientsshowingECGorbiomarkerevidenceofinsultevenECGorbiomarkerevidenceofinsultevenintheabsenceofsignificantcardiacriskintheabsenceofsignificantcardiacriskfactors(adults)factors(adults)StunnedmyocardiumStunnedmyocardium

Satran,etal.2005

DelayedDelayedNeurologicNeurologicInjuryInjury

PostischemicPostischemicreperfusionphenomenonreperfusionphenomenonMayoccurwithin20daysofexposureMayoccurwithin20daysofexposureMayincludeataxia,seizures,andproblemswithMayincludeataxia,seizures,andproblemswithmemory,attention,andconcentrationmemory,attention,andconcentrationCognitive,neurological,andpsychiatricCognitive,neurological,andpsychiatricsymptomslasting1monthormorereportedlysymptomslasting1monthormorereportedlyoccurin25%to50%ofpatientswithLOCoroccurin25%to50%ofpatientswithLOCorcarboxyhemoglobincarboxyhemoglobinlevelsgreaterthan25%levelsgreaterthan25%

Weaver,etal2002

DiagnosisDiagnosis

PulsecannotPulsecannotdistinguishbetweendistinguishbetweenOHbOHbandandCOHbCOHbPaO2willbenormalPaO2willbenormalRequiresmeasurementRequiresmeasurementofSaO2andofSaO2andCOHbCOHb(co(cooximeteroximeter))SaO2lowerthanSaO2lowerthanexpectedfromPaO2expectedfromPaO2

Parker,SJ,Tremper,KK,Anesthesiology198766:677

ManagementManagement

RemovaloftheRemovalofthesourceofCOsourceofCOHighflowoxygenHighflowoxygenbyfacemaskbyfacemaskConsiderConsiderintubationintubationConsiderConsiderhyperbaricoxygenhyperbaricoxygen

www.coheadquarters.com/coremove1.htm

ManagementManagementIndicationsforHBO2IndicationsforHBO2

NoclearguidelinesinmedicalNoclearguidelinesinmedicalliteratureliteratureCOHbCOHblevelabove25%levelabove25%EvidenceofongoingendEvidenceofongoingendorganorganischemia(ischemia(abnabnneurocognitiveneurocognitivefunction,function,evidenceofcardiacdysfunction)evidenceofcardiacdysfunction)LossofconsciousnessLossofconsciousness

TakeHomePointsTakeHomePoints

ImportanttopayattentiontoredflagsImportanttopayattentiontoredflagswhenpresentedwithcaseofsyncopewhenpresentedwithcaseofsyncopeCarbonmonoxidepoisoningcanbeanCarbonmonoxidepoisoningcanbeanfatalbuttreatablecauseoffatalbuttreatablecauseofsyncopesyncopeNormaloxygenationbystandardpulseNormaloxygenationbystandardpulseoximeteroximetercanbeverymisleadingcanbeverymisleadingneedneeddirectmeasurementofSa02anddirectmeasurementofSa02andCOHbCOHbtotomakediagnosismakediagnosis

ReferencesReferences

SyncopeinpediatricpatientspresentingtoanSyncopeinpediatricpatientspresentingtoanemergencyemergencydepartment.Massindepartment.MassinMM,MM,BourguignontBourguignontA,A,CoremansCoremansC,C,ComtComtL,L,LepageLepageP,P,GGrardrardP.JP.JPediatrPediatr.2004Aug145(2):223.2004Aug145(2):22388

DiagnosticmiscuesincongenitallongDiagnosticmiscuesincongenitallongQTQTsyndrome.Taggartsyndrome.TaggartNW,NW,HaglundHaglundCM,TesterDJ,CM,TesterDJ,AckermanMJ.Circulation.2007MayAckermanMJ.Circulation.2007May22115(20):261322115(20):261320.20.

OrthostaticintoleranceinOrthostaticintoleranceinpediatrics.Stewartpediatrics.StewartJM.JJM.JPediatrPediatr.2002Apr140(4):404.2002Apr140(4):40411.Review.11.Review.

ReferencesReferencesCarbonmonoxidepoisoningmimickinglongCarbonmonoxidepoisoningmimickinglongQTinducedQTinducedsyncopeIrenesyncopeIreneMMOnvleeOnvleeDekkerDekker,,AndricaAndricaCHDeCHDeVriesVries,,andAandADerkDerkJanTenJanTenHarkelHarkelArchArchDisDisChild200792:244Child200792:244245.doi:10.1136/adc.2006.094193245.doi:10.1136/adc.2006.094193

AccuracyofECGinterpretationinthepediatricemergencyAccuracyofECGinterpretationinthepediatricemergencydepartment.Wathendepartment.WathenJE,JE,RewersRewersAB,AB,YetmanYetmanAT,SchafferAT,SchafferMS.AnnMS.AnnEmergEmergMed.2005Med.2005

SyncopeinchildrenandadolescentsandthecongenitalSyncopeinchildrenandadolescentsandthecongenitallongQTlongQTsyndrome.Khositsethsyndrome.KhositsethA,MartinezMW,DriscollA,MartinezMW,DriscollDJ,AckermanDJ,AckermanMJ.AmMJ.AmJJCardiolCardiol.2003Sep1592(6):746.2003Sep1592(6):7469.9.

ReferencesReferences

ThechildwhopassesThechildwhopassesout.Narchiout.NarchiH.PediatrH.PediatrRev.Rev.2000Nov21(11):3842000Nov21(11):38488

SyncopeandsuddendeathintheSyncopeandsuddendeathintheadolescent.Walshadolescent.WalshCA.AdolescCA.AdolescMed.2001Med.2001Feb12(1):105Feb12(1):10532.32.

KaoLW,KaoLW,NanagasNanagasKA.CarbonmonoxideKA.Carbonmonoxidepoisoning.poisoning.EmergEmergMedMedClinClinNorthAm.NorthAm.200422(4):985200422(4):9851018.1018.

ReferencesReferencesMartinJD,MartinJD,OsterhoudtOsterhoudtKC,ThomSR.RecognitionandKC,ThomSR.Recognitionandmanagementofcarbonmonoxidepoisoninginchildren.managementofcarbonmonoxidepoisoninginchildren.ClinClinPediatrPediatrEmergEmergMed.20001:244Med.20001:244250.250.

HampsonHampsonNB,NB,HampsonHampsonLA.CharacteristicsofheadacheLA.Characteristicsofheadacheassociatedwithacutecarbonmonoxidepoisoning.associatedwithacutecarbonmonoxidepoisoning.Headache.200242(3):220Headache.200242(3):220225.225.

VaronVaronJ,J,MarikMarikPE,PE,GrommGrommREREJrJr,etal.Carbon,etal.Carbonmonoxidepoisoning:areviewforclinicians.Jmonoxidepoisoning:areviewforclinicians.JEmergEmergMed.199917(1):87Med.199917(1):8793.93.

SatranSatranD,HenryCR,D,HenryCR,AdkinsonAdkinsonC,etal.CardiovascularC,etal.Cardiovascularmanifestationsofmoderatetoseverecarbonmonoxidemanifestationsofmoderatetoseverecarbonmonoxidepoisoning.JAmpoisoning.JAmCollCollCardiolCardiol.200545:1513.200545:15131516.1516.