Syncope in Childhood

CAUSES OF FAUNTING IN CHILDHOOD AND DIFFERENTIAL DIAGNOSIS

Causes of Short-Term Loss of Consciousness

• Seizure
• Pseudonoseizure (pseudoseizure or conditions that mimic a seizure)
• Syncope

Seizure:

• They are abnormal neural discharges seen in the cerebral cortex.
• Clinical findings; depends on the affected brain area.
• Seizures may occur as a result of a known cerebral injury or without detectable cerebral impairment.

Convulsion:

• Convulsion; It is a condition in which seizures are accompanied by motor abnormalities.
  • Seizure classification
  • According to clinical and ictal and interictal EEG findings
    • Partial
    • Generalized
  • According to etiology
    • Epileptic
    • Symptomatic (Non-Epileptic)

Partial seizure:

• Only one hemisphere of the brain; They are seizures that occur completely or partially.
• They cause motor, sensory, visual and autonomic symptoms.
• They are classified as simple partial and complex partial seizures.

Generalized seizures:

• They are seizures that involve the whole brain and cause very short or long-term loss of consciousness.
• They have a focal onset and can quickly generalize.
• Tonic, clonic, atonic, absence and myoclonic seizures can be counted in this group.

Epilepsy

• It is a chronic paroxysmal disorder.

Epilepsy

• It is a chronic paroxysmal disorder.
• It is characterized by afebrile seizures with no known cause.
• They may occur as a result of genetic disorders, neuropathological changes, chemical and physiological changes.

Causes:

• • Genetic factors
  • Congenital brain malformations
  • Destructive brain lesions
  • Tumors
  • Diseases that cause degenerative brain damage

Non-epileptic seizures,

• Encephalitis
• Meningitis
• Hypocalcemia
• Intracranial infections
• Hypomagnesemia
• High fever
• Hypoglycemia
• Ischemia
• Tr avma
• Intoxication
• Space-occupying lesions
• Intracranial hemorrhages
• Hyponatremia

 

SeizureSyncopeTriggering causeRareUsually sadness, stressSituationIn any caseFrequently when the patient is standing, crowded, hot or in stressful situationsOnsetCan often develop following sudden, short-term aura periods. It may develop following fainting, nausea, blackout, sweating, feeling of heatMotor activityOften tonic or tonic-clonic. Clonic movements often have characteristic amplitude and frequency. Automatism is observed in complex partial seizures. Mostly motionless, flaccid. Short-term tonic spasm, clonic, movements are uncoordinated, short-term and low-amplitude.

SeizureSyncopeSkin colorPale or redPaleBreathingWheezing, foaming from the mouthSlow, shallowIncontinenceFrequentlyRareTongue bitingFrequentlyRareVomitingRareFrequentlySelf injuryOftenRarePostictal stateOften dizziness, confusion or the patient falls asleepUsually no postictal changesLoss of consciousnessUsually minutesFrequently 10 seconds or more

 

• Syncope (fainting) is a short period of loss of consciousness that occurs due to reversible disorders in cerebral functions.
• Important points in the story;
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• Relating to the pre-attack
  • Position (lying, sitting, standing)
  • Activity (rest, exercise, change of position, urination, defecation, cough)
  • Predisposing factors (crowding, hot environment, standing for a long time, fear, pain)
• Onset of attack
  • Nausea, vomiting, sweating, aura, blurred vision, palpitations
• During or after the attack
  • Duration of loss of consciousness, skin color, respiration, palpitations, involuntary movements (tonic, clonic, myoclonic), relationship of movements with falling, tongue biting, confusion, incontinence, trauma)
• Out of attack history
  • Family history (sudden death, fainting, heart disease), metabolic disorder, history of heart disease, neurological disease, medications, characteristics of other attacks

 

• The most common mechanisms in its formation are;
  • Decrease in cardiac output
  • Arterial hypotension
  • Cerebral arterial obstruction

Decrease in cerebral blood flow due to.

• Heart diseases, non-cardiac causes, Hypoglycemia; It is a condition where the blood glucose level is lower than 40mg/dl.
• Symptoms due to hypoglycemia are divided into two;
• Symptoms due to CNS depression
•                (Convulsion, mental confusion, coma , restlessness, visual disturbances, strange behavior, apnea, headache)
• Symptoms due to increased epinephrine
•                (Tremor, tremor, sweating, tachycardia, weakness, anxiety, feeling of hunger)
• Presyncope symptoms do not improve by moving to a lying position.
• Hyperventilation is one of the psychogenic causes of syncope.
• Hypocapnia seen in hyperventilation syndrome causes dizziness and sometimes dizziness. It may cause syncope.
• CO2 accumulated as a result of slowing down of brain circulation causes vasodilation and increases local blood flow.
• The lack of CO2 causes narrowing in the brain arteries, causing symptoms of ischemia. Findings suggestive of hyperventilation:
• Paresthesia
• Drowsiness
• Dizziness
• Coldness
• Tetany (rare)
• Decreased venous return
• The return of a normal amount of venous blood to the heart is necessary to maintain normal left ventricular output and systemic pressure in balance.
•  Right atrial pressure is 5-10 mmHg lower than the venules. provides venous return.
• Increased intrathoracic pressure (Valsavra maneuver, cough, breath holding, tracheal obstruction)
• Decreased venous tone
• Decreased intravascular volume (leading to bleeding and dehydration secondary)
• In cases where venous return is impaired enough to critically reduce flow, syncope occurs.
• Causes due to cerebrovascular occlusion
• Symptoms:
• Feeling of fullness in the head
• Weakness
• Dizziness
• Very rare in children.
• Cerebrovascular occlusion. In related diseases, it is usually
• Hemiparesis
• Temporary blindness
• Diplopia
• Speech disorder
• Confusion
• Short-term neurological problems such as headache
• are observed.

Reflex and Situational Syncope

Reflex syncope:

• Reflex syncope is a type of syncope that is provoked by certain factors.
• It is often confused with breath-holding seizures.

Situational syncope: p>

• Syncope that occurs after situations such as coughing, defecation, micturation, lifting weight is defined as situational syncope.
• It is more common in adults than in children.

Orthostatic Hypotension

• Some mechanisms come into play to keep the cardiac rate and cerebral arterial blood pressure at an adequate level while the person is standing;

• Mechanical pumping effect of skeletal muscles in the venous pathway
• One-way opening venous valves
• Baroreflex-mediated arterial contractions
• Cerebral autoregulation
• Reflex sinus tachycardia

• In orthostatic hypotension, hypotension occurs without reflex tachycardia in the heart due to the lack or inadequacy of the normal adrenergic vasoconstriction mechanism that occurs in the arterioles and veins while standing.
• The person experiences prodromal symptoms. only feels dizzy.

• Long-term bed rest
• Standing for long periods
• There are precipitating factors such as conditions that reduce blood volume (bleeding, dehydration)

.

• Drugs that impair the sympathetic vasomotor response    (Ca channel blockers, antihypertensive drugs, vasodilators)
• Diuretics

o They worsen orthostatic hypotension.

• In patients thought to have orthostatic hypotension, blood pressure should be measured while sitting and standing.
• In patients with orthostatic hypotension, the Tilt test is positive. However, symptoms such as pallor, diaphoresis and hyperventilation seen in vasovagal syncope are observed. autonomic nervous system findings. Excessive salt intake in the diet strong>Vasovagal Syncope

  Physiopathology:

  • Normally, while standing, venous return decreases and cardiac output is maintained by increasing the pulse.
  • In sensitive individuals, sympathetic activity that increases the heart rate causes vagal activation through a reflex mechanism.
  • As a result, the pulse decreases, cerebral perfusion is impaired and loss of consciousness occurs.
  • Trigger factors. ;
    • Anxiety                         
    •    Hunger
    • Hot and humid environment
    • Crowded environments
    • Standing and standing still for long periods of time

   

  • • Fear
    • Pain
    • Blood drawing
    • Blood vision
    • It is characterized by prodromal symptoms and ends in about a minute.
    • Prodromal symptoms ;
    • Imbalance
    • Darkness
    • Palpitation
    • Platancy
    • Nausea
    • Diaphoresis
    • Hyperventilation

  Tests to be performed for diagnosis;

  • • ECG
    • EEG
    • Glucose tolerance test
    • Echocardiography
    • CT
    • MR
    • Tilt test
  • Laying the fainting patient on a flat surface and elevating the legs is usually effective.
  • Prevention
    • Avoiding precipitating factors
    • Drugs
      • Pseudoephedrine-Prevents venous pooling and hypotension
      • Metoprolol-Negative inot

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