PediatricMorningReport

PediatricMorningReport
July20,2009
July20,2009
Claudia
Claudia
Algaze
Algaze
Objectives
Objectives
Presentacaseofsyncope
Presentacaseofsyncope
Facilitatediscussionofcausesof
Facilitatediscussionofcausesof
syncope
syncope
Presentationofthecauseofsyncope
Presentationofthecauseofsyncope
inourpatient
inourpatient
Takehomepoints
Takehomepoints
Relevance
Relevance
Commonpresentationtopediatric
Commonpresentationtopediatric
clinincs
clinincs
andemergencydepartments
andemergencydepartments
Canbeasymptomoflifethreatening
Canbeasymptomoflifethreatening
illness
illness
Highlightadiagnosisthatmay
Highlightadiagnosisthatmay
frequentlybemissed
frequentlybemissed
CaseReport
CaseReport
9yearoldfemalepresentsto
9yearoldfemalepresentsto
pediatricEDafteranepisodeof
pediatricEDafteranepisodeof
syncope.
syncope.
Priortothisshehashad4episodes
Priortothisshehashad4episodes
ofpre
ofpre

syncopeinthelast1
syncopeinthelast1

2months
2months
Noothersignificantpastmedical
Noothersignificantpastmedical
history
history
Shetakesnomedications
Shetakesnomedications
CaseReportContinued
CaseReportContinued
Describesfeelingdizzyandthen
Describesfeelingdizzyandthen
feelingasshe
feelingasshe

isgoingtopassout
isgoingtopassout

Shefeelsnauseousanddevelopsa
Shefeelsnauseousanddevelopsa
headacheduringevents
headacheduringevents
Pre
Pre

syncopal
syncopal
episodeshaveoccurred
episodeshaveoccurred
whilesittingatherdeskinherroom
whilesittingatherdeskinherroom
CaseReportContinued
CaseReportContinued
Episodeofsyncopeoccurredone
Episodeofsyncopeoccurredone
hourpriortopresentationwhileshe
hourpriortopresentationwhileshe
wasrunningplayingaroundwith
wasrunningplayingaroundwith
friendsoutsideofherhome
friendsoutsideofherhome
Nonoticeablepalpitations
Nonoticeablepalpitations
Nofamilyhistoryofsyncope,sudden
Nofamilyhistoryofsyncope,sudden
cardiacdeath,congenitalheart
cardiacdeath,congenitalheart
disease,orseizures
disease,orseizures
InitialEvaluation
InitialEvaluation
Temp36.5
Temp36.5

C,HR110,RR35,100%
C,HR110,RR35,100%
O2,BP110/75,
O2,BP110/75,
orthostatics
orthostatics
normal
normal
Completephysicalexaminationreveals
Completephysicalexaminationreveals
somewhatpaleandtiredappearing
somewhatpaleandtiredappearing
child,withmildtachycardiaand
child,withmildtachycardiaand
tachypnea
tachypnea
Physicalexaminationisotherwise
Physicalexaminationisotherwise
normal
normal
Whatdiagnosesareyouconsidering
Whatdiagnosesareyouconsidering
atthistime?
atthistime?
DefinitionofSyncope
DefinitionofSyncope
Syncope=transientlossofconsciousness
Syncope=transientlossofconsciousness
&muscletonemostoftendueto
&muscletonemostoftendueto
inadequatecerebralperfusion
inadequatecerebralperfusion
Pre
Pre

syncope=thefeelingthatoneis
syncope=thefeelingthatoneis

abouttopassout
abouttopassout

butnolossof
butnolossof
consciousness
consciousness
HowCommonIsIt?
HowCommonIsIt?
Variouscaseseriesestimatethat
Variouscaseseriesestimatethat
15%ofchildrenwillhavesyncope
15%ofchildrenwillhavesyncope
Amongchildrenandadolescents,
Amongchildrenandadolescents,
mostcommonlyoccursin15
mostcommonlyoccursin15

19year
19year
olds
olds
Represents3%ofpediatricEDvisits
Represents3%ofpediatricEDvisits
CausesofSyncope
CausesofSyncope
Neurocardiogenic
Neurocardiogenic
Neurologic
Neurologic
Cardiac
Cardiac
Psychogenic/
Psychogenic/
BreathHolding
BreathHolding
Intoxication
Intoxication
Metabolic
Metabolic
(Hypoglycemia)
(Hypoglycemia)
Obstructive
Obstructive
Respiratory
Respiratory
Disease
Disease
Situational
Situational
RedFlags
RedFlags
Knownheart
Knownheart
disease
disease
Recurrentevents
Recurrentevents
Suddenfainting
Suddenfainting
(no
(no
prodrome
prodrome
)
)
Faintingduring
Faintingduring
exercise
exercise
Knowningestionor
Knowningestionor
exposure
exposure
Abnormalrhythm/
Abnormalrhythm/
palpitations
palpitations
Injuryduringevent
Injuryduringevent
Abnormalrhythm/
Abnormalrhythm/
palpitations
palpitations
Neurologic
Neurologic
signsor
signsor
symptoms
symptoms
BackToOurPatient
BackToOurPatient
Complainsofheadacheandacute
Complainsofheadacheandacute
chesttightness
chesttightness
EKGrevealsSTsegmentelevationin
EKGrevealsSTsegmentelevationin
anteriorandlateralleads
anteriorandlateralleads
CXRisnormal
CXRisnormal
InitialABGisnormal,
InitialABGisnormal,
lytes
lytes
normal
normal
CK
CK

MBis80U/LTIis15
MBis80U/LTIis15
ng
ng
/ml
/ml
BackToOurPatient
BackToOurPatient
Thepatient
Thepatient

smotherrecallsshehasalso
smotherrecallsshehasalso
beenhavingheadacheslately
beenhavingheadacheslately

.
.
ABGwithco
ABGwithco

oximetry
oximetry
forevaluationby
forevaluationby
gaschromatographyisperformed
gaschromatographyisperformed
CarbonMonoxidePoisoning
CarbonMonoxidePoisoning
www.homepage.montana.edu/.../18AirPollution.ppt
SomeFacts
SomeFacts
Formedbyhydrocarboncombustion
Formedbyhydrocarboncombustion
Normal
Normal
COHb
COHb
inbloodis1
inbloodis1

2%(metabolism,
2%(metabolism,
ambient)
ambient)
Odorless,tasteless,colorless,non
Odorless,tasteless,colorless,non

irritant
irritant
Oneoftheleadingcausesofpoisoningdeath
Oneoftheleadingcausesofpoisoningdeath
intheUnitedStates
intheUnitedStates
Inadvertentcasesofpoisoningmostlyby
Inadvertentcasesofpoisoningmostlyby
smokeinhalation
smokeinhalation
Kao,etal.2004
handyman247.ie/carbonmonoxide.html
Pathophysiology
Pathophysiology
www.empowher.com/.../carbonmonoxidepoisoning www.cyberounds.com/cmecontent/art332.html
DegreeofCOHbis
afactorofrelative
amountsofCOand
O2inenvironment,
durationof
exposure,and
minuteventilation
www.lambtonfireservices.com/
Nonspecific
signsand
symptomsmay
leadto
misdiagnosis
Kao,etal.2004and
Martin,etal2000
MyocardialInjury
MyocardialInjury
Earlyeffectsfromresponsetohypoxia
Earlyeffectsfromresponsetohypoxia
Hypotension,
Hypotension,
dysrhythmia
dysrhythmia
,ischemia,or
,ischemia,or
infarctioninsignificantexposure
infarctioninsignificantexposure
Seriesshowed37%ofpatientsshowing
Seriesshowed37%ofpatientsshowing
ECGorbiomarkerevidenceofinsulteven
ECGorbiomarkerevidenceofinsulteven
intheabsenceofsignificantcardiacrisk
intheabsenceofsignificantcardiacrisk
factors(adults)
factors(adults)
Stunnedmyocardium
Stunnedmyocardium
Satran,etal.2005
Delayed
Delayed
Neurologic
Neurologic
Injury
Injury
Postischemic Postischemicreperfusionphenomenon reperfusionphenomenon
Mayoccurwithin20daysofexposure Mayoccurwithin20daysofexposure
Mayincludeataxia,seizures,andproblemswith Mayincludeataxia,seizures,andproblemswith
memory,attention,andconcentration memory,attention,andconcentration
Cognitive,neurological,andpsychiatric Cognitive,neurological,andpsychiatric
symptomslasting1monthormorereportedly symptomslasting1monthormorereportedly
occurin25%to50%ofpatientswithLOCor occurin25%to50%ofpatientswithLOCor
carboxyhemoglobin carboxyhemoglobinlevelsgreaterthan25% levelsgreaterthan25%
Weaver,etal2002
Diagnosis
Diagnosis
Pulsecannot
Pulsecannot
distinguishbetween
distinguishbetween
OHb
OHb
and
and
COHb
COHb
PaO2willbenormal
PaO2willbenormal
Requiresmeasurement
Requiresmeasurement
ofSaO2and
ofSaO2and
COHb
COHb
(co
(co

oximeter
oximeter
)
)
SaO2lowerthan
SaO2lowerthan
expectedfromPaO2
expectedfromPaO2
Parker,SJ,Tremper,KK,Anesthesiology198766:677
Management
Management
Removalofthe
Removalofthe
sourceofCO
sourceofCO
Highflowoxygen
Highflowoxygen
byfacemask
byfacemask
Consider
Consider
intubation
intubation
Consider
Consider
hyperbaricoxygen
hyperbaricoxygen
www.coheadquarters.com/coremove1.htm
Management
Management

IndicationsforHBO2
IndicationsforHBO2
Noclearguidelinesinmedical
Noclearguidelinesinmedical
literature
literature
COHb
COHb
levelabove25%
levelabove25%
Evidenceofongoingend
Evidenceofongoingend

organ
organ
ischemia(
ischemia(
abn
abn
neurocognitive
neurocognitive
function,
function,
evidenceofcardiacdysfunction)
evidenceofcardiacdysfunction)
Lossofconsciousness
Lossofconsciousness
TakeHomePoints
TakeHomePoints
Importanttopayattentiontoredflags
Importanttopayattentiontoredflags
whenpresentedwithcaseofsyncope
whenpresentedwithcaseofsyncope
Carbonmonoxidepoisoningcanbean
Carbonmonoxidepoisoningcanbean
fatalbuttreatablecauseof
fatalbuttreatablecauseof

syncope
syncope

Normaloxygenationbystandardpulse
Normaloxygenationbystandardpulse
oximeter
oximeter
canbeverymisleading
canbeverymisleading

need
need
directmeasurementofSa02and
directmeasurementofSa02and
COHb
COHb
to
to
makediagnosis
makediagnosis
References
References
Syncopeinpediatricpatientspresentingtoan Syncopeinpediatricpatientspresentingtoan
emergency emergencydepartment.Massin department.MassinMM, MM,
Bourguignont BourguignontA, A,Coremans CoremansC, C,Comt Comt L, L,Lepage Lepage
P, P,G G rard rardP.J P.JPediatr Pediatr.2004Aug145(2):223 .2004Aug145(2):223 8 8
Diagnosticmiscuesincongenitallong Diagnosticmiscuesincongenitallong QT QT
syndrome.Taggart syndrome.TaggartNW, NW,Haglund HaglundCM,TesterDJ, CM,TesterDJ,
AckermanMJ.Circulation.2007May AckermanMJ.Circulation.2007May
22115(20):2613 22115(20):2613 20. 20.
Orthostaticintolerancein Orthostaticintoleranceinpediatrics.Stewart pediatrics.Stewart
JM.J JM.JPediatr Pediatr.2002Apr140(4):404 .2002Apr140(4):404 11.Review. 11.Review.
References
References
Carbonmonoxidepoisoningmimickinglong Carbonmonoxidepoisoningmimickinglong QTinduced QTinduced
syncopeIrene syncopeIreneM MOnvlee Onvlee Dekker Dekker, ,Andrica AndricaCHDe CHDeVries Vries, ,
andA andADerk DerkJanTen JanTenHarkel HarkelArch ArchDis DisChild200792:244 Child200792:244
245.doi:10.1136/adc.2006.094193 245.doi:10.1136/adc.2006.094193
AccuracyofECGinterpretationinthepediatricemergency AccuracyofECGinterpretationinthepediatricemergency
department.Wathen department.WathenJE, JE,Rewers RewersAB, AB,Yetman YetmanAT,Schaffer AT,Schaffer
MS.Ann MS.AnnEmerg EmergMed.2005 Med.2005
Syncopeinchildrenandadolescentsandthecongenital Syncopeinchildrenandadolescentsandthecongenital
longQT longQTsyndrome.Khositseth syndrome.KhositsethA,MartinezMW,Driscoll A,MartinezMW,Driscoll
DJ,Ackerman DJ,AckermanMJ.Am MJ.AmJ JCardiol Cardiol.2003Sep1592(6):746 .2003Sep1592(6):746 9. 9.
References
References
Thechildwhopasses Thechildwhopassesout.Narchi out.NarchiH.Pediatr H.PediatrRev. Rev.
2000Nov21(11):384 2000Nov21(11):384 8 8
Syncopeandsuddendeathinthe Syncopeandsuddendeathinthe
adolescent.Walsh adolescent.WalshCA.Adolesc CA.AdolescMed.2001 Med.2001
Feb12(1):105 Feb12(1):105 32. 32.
KaoLW, KaoLW,Nanagas NanagasKA.Carbonmonoxide KA.Carbonmonoxide
poisoning. poisoning.Emerg EmergMed MedClin ClinNorthAm. NorthAm.
200422(4):985 200422(4):985 1018. 1018.
References
References
MartinJD, MartinJD,Osterhoudt OsterhoudtKC,ThomSR.Recognitionand KC,ThomSR.Recognitionand
managementofcarbonmonoxidepoisoninginchildren. managementofcarbonmonoxidepoisoninginchildren.
Clin ClinPediatr PediatrEmerg EmergMed.20001:244 Med.20001:244 250. 250.
Hampson HampsonNB, NB,Hampson HampsonLA.Characteristicsofheadache LA.Characteristicsofheadache
associatedwithacutecarbonmonoxidepoisoning. associatedwithacutecarbonmonoxidepoisoning.
Headache.200242(3):220 Headache.200242(3):220 225. 225.
Varon VaronJ, J,Marik MarikPE, PE,Gromm GrommRE REJr Jr,etal.Carbon ,etal.Carbon
monoxidepoisoning:areviewforclinicians.J monoxidepoisoning:areviewforclinicians.JEmerg Emerg
Med.199917(1):87 Med.199917(1):87 93. 93.
Satran SatranD,HenryCR, D,HenryCR,Adkinson AdkinsonC,etal.Cardiovascular C,etal.Cardiovascular
manifestationsofmoderatetoseverecarbonmonoxide manifestationsofmoderatetoseverecarbonmonoxide
poisoning.JAm poisoning.JAmColl CollCardiol Cardiol.200545:1513 .200545:1513 1516. 1516.