Latest / Pediatrics in Practice: A CME Podcast / When Should Teen Fainting Trigger Cardiac Referral?

Transcript

When Should Teen Fainting Trigger Cardiac Referral? · Pediatrics in Practice: A CME Podcast

• 0:03
  Dr. Sarah Gubara (Host):
• 0:03
  Welcome to Pediatrics in Practice, a CME podcast.
• 0:07
  I'm Dr.
• 0:08
  Sara Gubara.
• 0:09
  And today, I'm joined with Dr.
• 0:11
  Josh Holbert, Medical Director of the Cardiology Exercise Lab and
• 0:15
  Cardiologist at Children's Mercy.
• 0:18
  Today, we're exploring syncope in adolescents.
• 0:21
  Dr.
• 0:21
  Holbert, thank you so much for taking the time to join us this morning.
• 0:25
  Dr. Josh Holbert:
• 0:25
  Thanks, Dr.
• 0:26
  Gubara, for having me.
• 0:26
  I'm really excited to talk about this topic and something that's
• 0:30
  very prevalent in our community.
• 0:32
  Host: Absolutely.
• 0:33
  Since syncope is so common in kids and teens, what features can help distinguish
• 0:38
  a benign fainting episode from something that warrants a cardiac workup?
• 0:44
  Dr. Josh Holbert:
• 0:44
  So, syncope or fainting and collapse, as I describe to our patients,
• 0:48
  is a very common referral that we see in the cardiology clinic.
• 0:51
  However, it's frequently an encounter our primary care practitioners see
• 0:55
  and should also feel empowered to manage in their clinical setting.
• 0:58
  And so, the most recent joint statement from the American College of Cardiology
• 1:03
  and the American Heart Association and Heart Rhythm Society states that
• 1:08
  all pediatric patients who undergo a syncopal episode and should have a
• 1:12
  syncope evaluation that consists of a detailed history, physical exam, family
• 1:18
  history, as well as a 12-lead ECG.
• 1:21
  Most of these episodes tend to be vasovagal, or also known as a
• 1:25
  neural-mediated syncope, and those tend to represent around 75% of the
• 1:30
  pediatric cases that we see overall.
• 1:33
  However, cardiac syncope can make up anywhere between 2% to 6% of those cases.
• 1:38
  And so, it carries the risk of sudden cardiac events and death.
• 1:41
  And so, features that should raise suspicion and indicate a further
• 1:45
  cardiac referral include an absence of prodromal symptoms, palpitations
• 1:51
  within seconds of preceding a loss of consciousness, lack of prolonged upright
• 1:56
  posture prior to an event, syncope during exercise or triggered by some
• 2:02
  sort of auditory or surprise emotional stimuli, family history of a sudden
• 2:07
  cardiac event or an abnormal physical exam or ECG findings should all prompt
• 2:13
  visiting us in the cardiology clinic.
• 2:15
  Host: Wow.
• 2:16
  So when an athlete presents with syncope, what are some key history questions
• 2:20
  pediatricians should ask right away?
• 2:23
  Dr. Josh Holbert:
• 2:23
  Obviously, in our pediatric patients communication and discernment
• 2:28
  can be challenging especially depending on the patient's age.
• 2:31
  But a key history a-and questions can be pivotal in guiding our clinical judgment
• 2:36
  and suspicions for further workup.
• 2:39
  And so, questions such as: did the patient experience a true loss of consciousness
• 2:43
  or was it just a near fainting episode?
• 2:46
  Did the event happen during or after the cessation of exercise?
• 2:51
  Was the collapse abrupt and unrecognized, or was it preceded
• 2:55
  by a vasovagal prodrome?
• 2:57
  And what I mean by that is that lightheadedness, dizziness, the
• 3:00
  feelings of temperature change, feeling hot and flushed and nauseous
• 3:04
  can all be prodromal symptoms.
• 3:06
  Were there palpitations and chest pain associated with the syncopal event?
• 3:11
  What other surrounding situational factors were at play, hydration,
• 3:15
  dietary habits that day?
• 3:17
  Was it a very hot day?
• 3:18
  Were they in a steam shower or a sauna?
• 3:21
  Were they currently ill at the time with any recent viral illnesses?
• 3:25
  And then, obviously in our teenagers, it's important to know the social
• 3:27
  history, such as recreational or performance-enhancing drug use.
• 3:32
  And then, lastly, the two other important questions are any prior syncopal episodes
• 3:36
  that the patient has experienced, and then that family history of cardiac
• 3:40
  diagnoses, such as any family members with congenital heart disease, arrhythmias.
• 3:45
  But also, asking not to forget that key question of any patients or family members
• 3:51
  that have experienced sudden, young or unexplained deaths in other family members
• 3:56
  Host: That's wonderful to know what specific things to look for.
• 4:00
  Now, should pediatricians look for any other specific red flags during exercise
• 4:06
  or competition that should prompt an urgent cardiac referral to your team?
• 4:10
  Dr. Josh Holbert:
• 4:10
  Yeah.
• 4:11
  It's something that I really highlight and want to drive home with
• 4:14
  my patients and families as well.
• 4:16
  And really, making them knowledgeable why I'm asking
• 4:19
  specific previous history questions and what I'm really screening for.
• 4:23
  And so, red flags for syncope include mid-exertional abrupt syncope or
• 4:28
  collapse with loss of consciousness, is arrhythmia until proven otherwise.
• 4:32
  So, that's a big one.
• 4:34
  Abrupt palpitations preceding an event, particularly if the patient in this
• 4:38
  day and age has tech that indicated an abnormally abrupt high heart rate, and
• 4:43
  especially if those high heart rates were not occurring with any strenuous activity.
• 4:47
  And so, you know, we see a lot of patients that come in with Fitbits or iWatches,
• 4:50
  things of that nature, that are triggering and alerting them to high heart rates.
• 4:54
  And so, another piece of key information that we can screen.
• 4:58
  Exertional chest pain that is associated with syncope episodes
• 5:02
  or just exertional chest pain alone at baseline should be sent for an
• 5:06
  echocardiogram and further assessment.
• 5:09
  Excessive shortness of breath or dyspnea that limits exercise outside of the normal
• 5:15
  capacity is something that is a red flag.
• 5:18
  Multiple syncopal episodes pertinent cardiac family history or family
• 5:23
  history of sudden cardiac death.
• 5:26
  All of these things are red flags that should require cessation of activities
• 5:30
  and sporting events until necessary evaluation and testing is completed.
• 5:34
  And also, while I am a cardiologist by trade, you can't forget the
• 5:39
  non-cardiac exertional symptoms that are associated with collapse and can
• 5:43
  nonetheless be just as emergent as well.
• 5:45
  So, things like seizure-like activity with rhythmic jerking
• 5:48
  movements with the syncopal episode.
• 5:50
  If this is, at the time, heat illness, possibly experiencing
• 5:54
  exertional hyponatremia, requires very acute treatment and reversal.
• 5:59
  And then, sickle cell can also be associated with acute
• 6:02
  chest pain and collapse.
• 6:02
  And so, all things outside of the heart that also need to be considered.
• 6:06
  Host: So Dr.
• 6:07
  Holbert, as pediatricians are thinking of sending a patient to cardiology,
• 6:13
  what initial evaluation can be completed in the primary care setting before
• 6:18
  that referral is submitted your way?
• 6:21
  Dr. Josh Holbert:
• 6:21
  Initial evaluation, yeah, is absolutely feasible in the primary care setting.
• 6:25
  And our primary care providers can be a huge aid in the first-line workup.
• 6:31
  As I stated earlier, obtaining that thorough history and exam, inspecting for
• 6:35
  those red flags, and then also obtaining that ECG, screening for any abnormalities
• 6:41
  as well as performing orthostatic vital signs in the clinic, which can identify,
• 6:45
  you know, a poor hydration status.
• 6:48
  And then, also performing targeted labs when the history suggests, you looking
• 6:51
  for things like anemia, electrolyte derangements, pregnancy, or ingestion.
• 6:56
  Those are all things that primary care providers should be comfortable obtaining.
• 7:00
  As we mentioned before, as the director of the cardiology exercise
• 7:04
  lab, I'll step on my soapbox just for a minute to also reiterate that tilt
• 7:08
  table testing is of very little and limited utility in pediatric patients.
• 7:13
  We've seen a lot of rise in referrals of this nature in the TikTok era for concerns
• 7:18
  of things like dysautonomia and POTS.
• 7:21
  And so, explaining to families that tilt table test after they do some
• 7:24
  Google searching does not have robust data in the pediatric realm.
• 7:27
  And so, trying to further delineate that and make them understand kind
• 7:31
  of what the scenario that they are faced with and what they may be
• 7:34
  receiving in the cardiology clinic.
• 7:36
  If it sounds, after all this inspection, like a vasovagal syncopal event, primary
• 7:41
  care providers should feel comfortable in instituting the initial treatments
• 7:45
  and recommendations to patients to increase their hydration levels
• 7:49
  supplement salting mechanisms, and encouraging exercise and activity as a
• 7:53
  conservative prophylactic measurements.
• 7:56
  Lastly, if the primary care provider deems that referral is necessary, sending
• 8:00
  along their key documentation of the up-to-date history, the current up-to-date
• 8:04
  workup that they have received, and any treatments that maybe they've instituted
• 8:08
  and the patient has been faithfully attuning to is something that's very, very
• 8:13
  helpful for us in the cardiology clinic.
• 8:15
  And, you know, as I said, I'm from Kansas City and a Chiefs fan.
• 8:18
  So, we love a good game plan.
• 8:20
  And so, the primary care providers can be very instrumental in that game plan
• 8:23
  in helping us treat these patients.
• 8:25
  Host: I appreciate you sharing what families might be researching on their
• 8:31
  spare time because there's a natural part of this process that's anxiety-inducing.
• 8:35
  And so, I'm curious to know, how do you counsel athletes and
• 8:39
  families about returning to sports while the evaluation is underway?
• 8:45
  Dr. Josh Holbert:
• 8:45
  it's one of the biggest key components of this type of visit.
• 8:49
  And it's a very common question when I speak on this topic at other events that
• 8:54
  providers will come and ask me as well.
• 8:56
  And it really hinges on the evaluation, right?
• 8:59
  So if the workup is largely reassuring and benign with episode
• 9:03
  consistent with a vasovagal syncope, we can clear them right away.
• 9:07
  We give them prophylactic interventions to prevent these episodes.
• 9:10
  And then, we make sure that they have those red flag features that we mentioned
• 9:14
  earlier that would require further testing past that appointment day.
• 9:18
  And that may be something like a Holter monitor that we can place on
• 9:21
  them scheduling and performing an echocardiogram, an exercise stress test.
• 9:26
  Or if we're concerned about congenital heart disease and coronary abnormalities,
• 9:30
  we may need to schedule a cardiac CT.
• 9:32
  And so, it's very important to tell parents if we aren't clearing them right
• 9:35
  away, that we must restrict patients from their activities until the full
• 9:39
  and complete evaluation is finished.
• 9:42
  And obviously, if all this comes back negative, reassuring them
• 9:46
  that we have done the appropriate workup and that they may rejoin in
• 9:48
  activities that we clear, but the caveat of watching for those warning
• 9:52
  signs that we discussed previously.
• 9:54
  As a former collegiate football player, I totally get the frustration
• 9:58
  of being held out, and it's tough to sideline our patients, but it's
• 10:02
  imperative that we set them up to succeed but also be safe in the arena.
• 10:06
  Despite our best efforts at times, sudden cardiac events can still happen.
• 10:10
  And so it's also why every school or athletic activity association should
• 10:15
  have an emergency action plan or an EAP.
• 10:18
  And that includes access to an AED CPR-certified staff, and a transportation
• 10:24
  plan for any incidents that would require further hospital evaluation.
• 10:27
  And so, I encourage our patients and families to familiarize themselves
• 10:31
  with these emergency action plans.
• 10:34
  And lastly, I'll kind of just plug, like you mentioned, as the sports and exercise
• 10:38
  cardiologist here at Children's Mercy.
• 10:40
  We're working to develop in our facility, our own cardiac fitness program and
• 10:44
  clinics, and that will include patients with and without cardiac pathology.
• 10:49
  And patients and providers who may desire further guidance or recommendations with
• 10:53
  sports and activities down the line.
• 10:55
  And we'll be excited to help them as we continue to develop
• 10:58
  those clinics in the near future.
• 11:00
  So, lots of exciting things on the horizon in this great kind of sports time.
• 11:04
  Host: That is exciting to know about these future interventions and
• 11:07
  wonderful work you're doing to get young athletes back to doing what they love.
• 11:13
  Dr. Josh Holbert:
• 11:13
  Yes, exactly.
• 11:14
  And that's the key thing.
• 11:15
  And so, it's a large percentage of patients that we see not
• 11:18
  only in our clinic, but also the primary care provider setting.
• 11:22
  And so, what we can do to help these athletes get back on the field and
• 11:25
  feel confident to perform to the best of their abilities is the best
• 11:29
  medicine for everyone involved.
• 11:31
  Host: Well, I appreciate that.
• 11:32
  That sounds wonderful.
• 11:33
  Thank you so much, Dr.
• 11:35
  Holbert, for taking the time to talk to us about syncope in athletes.
• 11:39
  Dr. Josh Holbert:
• 11:39
  Thank you, Dr.
• 11:40
  Guevara, for having me come speak today.
• 11:42
  I really appreciate it
• 11:44
  Host: Of course.
• 11:45
  And as a reminder to our audience, claim your CME credits after listening
• 11:49
  to this fascinating episode today.
• 11:51
  You can do so by visiting cmkc.link/cmepodcast,
• 11:57
  and then click the Claim CME button.
• 12:00
  If you enjoyed this podcast, please share it on your social channels
• 12:04
  and check out the entire podcast library for topics of interest to you.
• 12:08
  I'm Dr.
• 12:09
  Sara Gubara, and this has been Pediatrics in Practice, a CME podcast.