Shannon Jenkin Swiney, PNP, presents on the pathophysiology of the autonomic nervous system as well as the diagnosis, management and treatment of Autonomic Dysfunction.
Good morning, everyone. Um, welcome to the early bird rounds. Today we have Shannon Sweeney. Uh, The PNP who specializes in cardiology, and today we are speaking on understanding autonomic dysfunction in children, key insights and pediatric care. Please keep your cameras off, your mics muted during the session. There will be a time at the end for questions. You're welcome to unmute at that time and type in your questions and the chat. I will put a QR code um back up at the end for you to scan for credit. With that, with that said, uh, let's turn our attention to Shannon. Good morning, everyone. Like Tammy said, my name is Shannon. I'm a nurse practitioner here in Pete's cardiology at Washoe School of Meds. So I have no disclosures to report, and I just wanna say that the medications discussed during this are not FDA approved for the treatment of autonomic dysfunction. My objectives, as you can see here, just an introduction and then um tell you about about my experience. Talk about the pathophysiology of the autonomic nervous system, just a brief overview. The etiology and classification of autonomic dysfunction, symptoms of autonomic dysfunction, diagnosis, management and treatment, and then just to talk about our PAD clinic, our pediatric autonomic dysfunction clinic here at WasU School of Men. My name is Shannon. I've been here at WashU for many years. I was a nurse practitioner with Peeds Cardiology for the past 2 years, and before that, I was a nurse practitioner in Peed's cardiothoracic surgery. But I've been in um the WasU School of Med and also here at uh Barnes in Saint Louis Children's for many years. So the autonomic nervous system, it's part of the peripheral nervous system. It controls involuntary bodily functions. I know a lot of this is probably just a quick review. The main functions of the autonomic nervous system is to regulate both your heart and your respiratory rate, control your digestion, maintain homeostasis, management of the blood vessel diameter, and to control your glandular secretions. So there's two main divisions, the sympathetic and the parasympathetic, and the balance and coordination between these two ensure that the body can appropriately react to varying situations and maintain internal stability. As you can see here, this is just a um A diagram of the sympathetic and parasympathetic nervous system and what all it does. So your sympathetic nervous system is one of the main two divisions of the autonomic nervous system. It is the primary function is to prepare your body for situations that require energy expenditure. Often referred as the fight or flight. So the main functions is to increase your heart rate. Increase your blood pressure, dilate those airways, enhance your blood flow to all of your muscles, increasing your glucose availability, inhibit your digestion, increasing that metabolic rate, stimulating your adrenal glands, relaxing your bladder, stimulating that sweat production, dilating your pupils, and fight or flight response. And then you have your parasympathetic nervous system, decreasing that heart rate, lowering the blood pressure, constricting those airways, enhancing digestion. Promoting bladder contraction, stimulating your peristalsis, reducing your sweat production, your rest and digest, constricting those pupils, and stimulating sal salvation. So autonomic nervous system dysfunction, also known as dysaudenomia, vasovagal presyncope, you're dizzy and you don't pass out, you have symptoms and you don't pass out, vasovagal syncope, you have symptoms, you're dizzy and you do pass out. And POTS. Potts is postural orthostatic tachycardia syndrome, and to meet the criteria there's certain criteria to meet the POT's diagnosis doesn't really matter what we call it, it's autonomic nervous system dysfunction. So, call it whatever you want, dizziness, dys adenomia, whatever. um, some patients come to me for the diagnosis of POTS. Um, it seems that some people think that if you have a POTS diagnosis, that people will take you a little bit more seriously. So it is a group of disorders where the autonomic nervous system doesn't function properly. It affects various organ symptoms. It presents with very diverse symptoms, making the diagnosis very challenging, and it really can be complex and misunderstood. So there's different types of autonomic nervous system dysfunction. I see a lot of patients with vasovagal. So vasovagal syncope is the most common cause of fainting in children and adolescence, and it's due to the sudden drop in blood pressure and heart rate. Uh, it can be caused by standing for extended periods, long-term emotional stress, those kinds of things, fainting near fainting, especially after standing for those long periods, nausea, sweating, paleness before you faint. I see patients with POTS, postural orthostatic tachycardia syndrome, and that's an excessive increase in the heart rate upon standing, and it is between 30 and 40 beats per minute upon standing, and we'll talk about that a little bit more here. Lots of patients with POTs have that rapid heartbeat, dizziness, lightheadedness, fainting, fatigue, a lot of GI distress. I see patients with Eller-Danlos syndrome, and then also with that with that and then also has autonomic dysfunction as well. See some patients with pediatric chronic fatigue, it's a pretty complex disorder of extreme fatigue. Not so much in the pediatric population, but there is diabetic autonomic neuropathy. Familiar dysodenomia. I see a lot of patients whose whose parents, grandparents, aunts, uncles have problems with their autonomic nervous system, not necessarily saying that it is genetic, but it does seem to kind of track sometimes. And then multiple system atrophy. I don't necessarily see that that much in the. Pediatric population, but it does occur. So, causes of autonomic nervous system dysfunction. Orthostatic distress. A lot of patients prolonged standing, minimal oral intake. I cannot tell you how many patients I see on a daily basis, or I should say a weekly basis, that do not drink water. I saw a patient yesterday who drinks 6 Dr. Peppers in a day, doesn't drink water at all. There's a lot of Mountain Dew, there's a lot of energy drinks, caffeine, Starbucks, you name it. A lot of minimal oral intake. Just don't drink. Um, and then prolonged standing, we see a lot of patients that do marching bands that are in the choir, all of those kinds of um things where you're standing for long periods of time. Specific triggers, can't tell you how many patients I see after they get blood draw, they pass out. You can have specific triggers of fear, pain, phobias, and then in a very warm environment. Lot of weight lifters, a lot of patients that lift maybe a little bit too much weight, hold their breath, pass out. Not so much, um, in the pediatric facility um pediatric population, but you can have syncopee after you urinate. I do see a lot of patients that have gastrointestinal distress and do pass out while on the toilet. Then you get into your chronic illnesses. A lot of patients with IBS, Crohn's disease, ulcerative colitis. I have a 9 year old with ulcerative colitis. Her dad has ulcerative colitis, and she has POTS. A lot of patients, especially since the COVID pandemic, infections, viral, bacterial, influenza, toxic shock. We have a patient we're treating right now who has had, who had toxic shock a year and a half ago, and she's still having very bad autonomic dysfunction symptoms. Then you get into your Epstein-Bar long COVID. Lots of patients that had COVID and then developed autonomic nervous system dysfunction. Trauma or surgery, a lot of concussions, a lot of knee injuries, post-spinal fusion. I get a lot of athletes who have developed, um, excuse me, have developed autonomic nervous system dysfunction, symptoms after a concussion. Football players, baseball players, volleyball, softball. And then I do have a handful of patients that have had spinal fusions and then develop autonomic nervous system dysfunction. Your autoimmune disorders, celiac, lupus, mass cell activation syndrome. So, mass cell activation syndrome is pretty hard to diagnose in itself. You have to actually be in a flare to get that diagnosis, but we do see patients that have autonomic nervous system dysfunction, and then mass cell or have mass cell and then autonomic nervous system dysfunction. There are some genetic factors, not necessarily that you can Say my mom had dys adenomia, so I have dys adenomia, but like I said, there does seem to be some trend in parents, daughters. Sons, all of those kinds of things. Insomnia, a lot of kids do not get enough sleep, go to bed. Very late, um, stay up all night because they have a final stay up all night cause they didn't get their homework done. A lot of kids these days, a lot of pediatric patients these days are on the run. They have 4 or 5 different activities, doing things every night, not eating till 8 o'clock, 9 o'clock at night, getting that fast food, um, and then skipping lots of meals, not getting adequate sleep. See a lot of patients with headaches and migraines. Um, and then there are some idiopathic causes. Have a handful of patients that come to me and we find that they've had some vitamin deficiencies. And then possible autonomic nervous system cause is just deconditioning. Those patients that are couch potatoes that don't really get much rest, excuse me, don't really get much activity. Kind of the gamers, the patients that sit around all day and really don't get Um, the activity requirements or, you know, the cardiovascular exercise that they do need, that we all need. Symptoms of autonomic nervous system dysfunction. So you have those cardiovascular symptoms, orthostatic intolerance, dizziness, feeling like you're going to pass out, passing out, heart palpitations, tachycardia, bradycardia, those kinds of things. See a lot of patients with fatigue, brain fog, that sleep disturbance, insomnia, very poor sleep quality. And then some patients we see with pretty bad light sensitivity, end up having patients that are wearing sunglasses in class. Shortness of breath is seen a lot in autonomic nervous system dysfunction, those breathing difficulties. Um, I do see patients with vocal vocal cord dysfunction. And that can have some issues with your respiratory. System as well. So many patients with autonomic dysfunction have GI symptoms, belly aches, nausea, vomiting, constipation. Getting full after only having a couple bites. Patients with gastroparesis. Not so much in the pediatric population, but there can be urologic symptoms, urinary retention, incontinence. I do have one patient that I've seen that really went to the bathroom like once a day, even though, um, she had to go more. It's almost like you have to train your body to um. To use the restroom. And then you have those metabolic symptoms, temperature regulation impairment, hyper hydrosis, cold or heat intolerance. I saw a patient in clinic yesterday that has hyper hydrosis so bad that he has been having syncope and requiring. 1 L 2 L of fluid when he has really bad um flare-up of, of his hyper hydrosis. Thankfully, he has gotten into dermatology and his mom is um really on top of his fluid intake. So the diagnosis of autonomic nervous system dysfunction. Patient comes to my clinic, they have been referred for dizziness or heart palpitations. The first thing is to do a very comprehensive history. Detailed history of symptoms, the onset, the triggers, anything with the family, autoimmune disorders, anything like that. I really delve deep into when did this start? How long has this been going on? When does it happen? Did anything happen in your life? Were you ill? Did you have an injury? Did you have an illness? Did you have a significant stressor in your life? Surgery, all of those kinds of things. Um, when a patient comes to my clinic, I, they're usually in my clinic for a good 45 minutes just because a lot of it is the history. The physical exam, we do orthostatic vital signs. If you are coming into the PAD clinic and you have dizziness, that's the first thing, is the active scan test, those orthostatic vitals. And it's the vital sign measurements, you lay down for 10 minutes, and then you get a baseline heart rate and blood pressure, and then you're standing up between 5 to 10 minutes and standing still, getting that blood pressure and those heart rate to see what your heart rate, um, elevation is, if there even is any elevation. There are a few institutions that perform a tilt table test. There is not currently a pediatric institution. There is a neurologist that is at Cardinal Glennon, and she's trying to get a tilt table lab set up. If you do want a tilt table for your patient, a lot of times you have to be 18 years old. So, um, or you have to travel. I know that the Mayo Clinic does it. There's a couple other institutions, but most pediatric facilities just do the active scan test, the orthostatic vitals. Um, if you're over the age of 18, there are some providers in the county that do, uh, perform tilt table. But the waiting list is pretty long. And then we do tests, blood work to rule out other causes. What's your blood count look like? Do you have really horrible, uh, teenage girls with menorrhagia, and do you have really, really heavy menstrual cycle, and you have low blood counts? Are you anemic? Um, Other patients, what does your iron look like? Specifically your ferritin, vitamin D, vitamin B12. I have a handful of patients, and I actually learned this from a parent, um, that vitamin B12 deficiencies can cause autonomic nervous system dysfunction, and she knew that specifically because she herself had a low vitamin B12. What is your thyroid look like? Thyroid studies. Um, so, like I said, the CBC CMP, TSH 3 T4, or your thyroid cascade, function cascade. Your ferritin, your vitamin D, your B12. I don't necessarily jump right to blood work. Sometimes we talk about the non-pharmacologic things first, and let's try this, and then if this doesn't um make things better, then we'll go into, well, delve deeper into, is it your thyroid? Do you have really low vitamin D because you're never outside and you don't drink any milk? Those kinds of things. So the POTS diagnostic diagnostic criteria. So, to meet the diagnostic criteria for POTS, you have the patient lay down for 10 minutes, and then you do the serial blood pressure, and Um, heart rate. Measurements. So, to meet the pot's criteria, you have to have a heart rate elevation of 40 points with your change in your position. So you do line to sitting, line to standing, but with those vital signs, it is lay down for 10 minutes and then stand up. And then a lot of patients, if they have the heart rate above 120, For a prolonged period of time, you also can make the POT's diagnosis. And then if you're over the age of 19, it's a heart rate elevation of 30 points. So, under 1940 points, over 1930 points. So just in a review for that active scan test, the orthostatic vitals, it's the bedside measurement, patient comes in. Usually gets their height, their weight, their blood pressure, um, just their baseline things. If they need an EKG they get an EKG. If you're coming to a cardiologist, you're gonna get an EKG and then we have them lay down right away. So that also can be a little time, um. Time taker, uh, take up a lot of time, and that's another reason why my, my slots, my template is a little bit longer, because those vital signs before you see me, um, can be time consuming. So, the blood pressure, heart rate, when you're lying down for 10 minutes and then we do 1 minute. 2 minutes, 3 minutes and 5 minutes, or 1 minute, 3 minutes and 5 minutes. You don't necessarily have to do it up to 10 minutes. I do do have some patients that I have stand for 10 minutes. It's not a hard and fast rule that you have to stand for the 10 minutes. You can usually get the information within 5 minutes of the patient standing. Management and treatment. Unfortunately, this is one of the hardest. There's no one size fits all treatment. The plan must be tailored based on the symptoms, the severity. It's really, really beneficial if we get these kids early into the clinic. And then there is a comprehensive management plan, and then the most important treatments are non-pharmacologic. I cannot stress that enough to my patients. A lot of patients come in and they want a quick fix. They wanna feel better. They don't want to go through this any longer, um, but it really is a chronic, um, condition. And it's can be lifelong. The non-pharmacologic management, this is so key in the treatment of autonomic nervous system dysfunction. So, I go through the whole spiel with my patients, do the exam, and then it's the counseling. So the lifestyle modifications, 80 to 100 ounces of non-sugary, non-caffeinated beverages a day. Monday through Sunday. It doesn't matter if you're sitting around. You really gotta fill up your tank. I explained to my patients, you have to treat your water, you have to treat your body like a water bottle. Fill up that water bottle, fill up that tank. The more fluid you have in your system, the more blood you have in your system, and the more it makes up for that twitchy autonomic nervous system. So, I really do say 80 to 100 ounces of non-sugary, non-caffeinated, containing beverages. Sugar and caffeine make you urinate. They're dehydrating. So it really needs to be non-sugary, non-caffeinated. I tell patients if they want to have a coffee, if they want to have a soda, um, really try to minimize it to not an everyday occurrence, and if anything, to increase your non-sugary, non-caffeinated beverages. If you are drinking caffeine and sugar. A lot of patients come into my clinic and tell me, well, I drink a lot of Gatorade and I drink this, and I drink this without knowing that some of these fluids do have a significant amount of sugar in them. A regular Gatorade, depending on what size you get, is in flavor, quite frankly. 27 to 35 g of sugar. So a lot of patients come and say, well, I've been rehydrating with Gatorade, not knowing that full strength Gatorade, the regular Gatorade, does have a significant amount of sugar in it. Lots of patients are skipping meals, skipping breakfast, running out the door to get to school. It really is important to have 3 meals a day. If you have belly trouble, if you have gastroparesis, if you have, um, lots of abdominal bloating and abdominal pain, then try to do small frequent meals. I always tell patients that breakfast is the most important part of the day. Um, and they really have to try to put at least something in their tummies. So, granola bar. Um, I'll tell you that one of our cardiologists, she hates breakfast, but she drinks Carnation Instant breakfast every single morning. Those protein shakes, some of those other things that are less sugar in them, but more protein are very beneficial. I always tell a patient, try to at least eat something. And then you have your salty snacks. I give out a list of all kinds of salty snacks that a patient can ingest in a day. You should try to have 2 to 3. So salty snacks, add salt to your food, salt supplementation, um, to increase blood volume. You can get sodium chloride tablets at Walmart. Sodium chloride tablets that I can prescribe are the 1 g tablets, and then I tell patients 1 g 3 times a day, so 3 tablets. And then if they're still having symptoms, you can even go up to 2 g, uh, 3 times a day, so 6 g of So, um, if you don't have Any cardiac symptoms, which, uh, or I, I usually tell a patient, you're only 15, you're only 16, we've done an EKG, we've done an echo. We know that your heart is healthy and salt is not bad if you don't have coronary artery disease. There's a lot of patients that stray away from salt. I think we're taught as a society that salt is bad, but salt is bad for high blood pressure, high cholesterol, and people that have been in this world long enough to have wear and tear of our hearts. So, salt isn't so good maybe for us. Excuse me. There are a lot of supplements that you can eat, drink. I tell my patients, look at your electrolytes. You can do like a, I'm already telling you to drink 80 to 100 ounces of water, but liquid IV element, there's all kinds of different supplements, um, different electrolyte beverages that you can drink, even if you, um, don't necessarily prefer water. You can add things to your water, but you want that to, you wanna make sure it doesn't have a ton of sugar in it. A mediocre plan is better than a perfect plan. So if a patient tells me that they. They are wanting to put some electrolytes in their water, but they actually absolutely hate the way liquid Iy tastes or element tastes, or salt tastes. Um, mediocre plan is better than a perfect plan. So if your patient is gonna drink something along the lines of a Gatorade, G2, uh, 0, those kinds of things, um, but they're gonna actually drink it, then obviously go down that route. And then good sleep hygiene. It's good to try to go to bed around the same time every night, wake up around the same time every morning, not mess with that time frame, more than like 2 hours each way. And then if you're taking a nap, not to nap longer than 1 hour at a time, try to get some water, take a little walk around your house, those kinds of things. Try to prevent um sleeping unless unless it's nighttime. Um, and really not to be in your bed unless you are sleeping. Go to bed around the same time, wake up around the same time, turn that cell phone off, try to really get into the mode of relaxation. Exercise can really improve your symptoms, especially with patients in pots, regular structured exercise, swimming, cycling. If you Google Chop pots exercise protocol, there's a huge packet that everyone gives out to their patients, um, multiple institutions all over. Um, I see tons of people, um, tons of colleagues that give this out. Um, it is a pretty Um, regimented program that you can you can skip. It doesn't have to be like you can fast forward if you, if you're doing well. Just to kind of depends on deconditioning. And then physical therapy, um, we can, we can send a patient for physical therapy, and then we have a program that we're working on here at WashU. Coression garments. I tell my patients, try some compression, so that's your socks, your stockings, undergarments, leggings, bike shorts, anything that can help prevent venous pooling. And then anti-gravity maneuvers, so trying to prevent those triggers, taking your time when you're going from align to sitting, sitting to standing. Maybe stay in bed for a couple minutes, but put a bunch of pillows behind your back. Elevate those feet up on your wall. Try to avoid sudden movements. Really want to try to do non-pharmacologic before pharmacologic. So I always say, well, excuse me, water, salt, anti-gravity maneuvers, compression. All of those things, if you're not doing those things, especially water, salt, and anti-gravity maneuvers in getting exercise, pharmacologic treatment isn't going to help you. If we find that your iron level is low, your calcium level is low, your vitamin B12 level is low, just treating those things, writing for some iron, writing for some calcium. The medication that I normally would prescribe at first, my initial would be fludrocortisone. It helps to increase your blood volume. Um, you can go up, um, the initial dose for fludrocortisone is 0.05 or 0.1. And then you can go up to 0.2. So you really have to try to give time for that fludrocortisone to work. So if I'm going to prescribe the fludrocortisone, they need to be on it a good 2 to 3 weeks before we decide, is this working, is this not working. The fludrocortisone is not going to work if you're not drinking that fluid. So, Baseline, 80 to 100. If the fludrocortisone doesn't work, if we decide to try a different medication, the next line would be Meadrine. So wean off of that pludrocortisone. Try Medrine. Midedrin is a vasoconstrictor. It's used to help, uh, to raise your blood pressure. I do have a handful of patients on midadrine, but it is not my number one choice, and it's not my number one choice because um it can cause some rebound hypertension. A lot of patients don't know that after you take Midadrine, you really shouldn't lay down for 4 hours. Um, you can do midadrine twice a day, 3 times a day. I do have some patients that take it in the morning. Sometimes just once a day. Take it in the morning, take it in the late afternoon, and then don't take it at night. So I always say to my patients, just really make sure that you make it so that you're not taking it within 4 hours of laying down. Beta blockers can be prescribed for autonomic nervous system dysfunction. I have a lot of patients that come in with headaches, and they've already been prescribed a beta blocker like propranolol from the neurologist. It can manage tachycardia and palpitations, but beta blockers aren't my number one choice for a pediatrics because it can interfere with your mental health. Um, if you already have baseline anxiety, baseline depression, it can increase it. And then Avaridine. So we have a handful of patients in the PAD clinic that are on Avaridine. It's just an alternative medication for controlling heart rate. A lot of patients that have heart failure on are on avaridine, so you can do um avaridine for inappropriate sinus tachycardia. Evaridine is hard to get pre-cerated for, um, so you really have to show medication failure of those other medications. And then your mental health is as important as your physical health. I really stress that to my patients. So treating underlying anxiety and depression can exacerbate autonomic nervous system dysfunction. So maintaining mental health, going to a psychologist, psychiatrist, those kinds of things are very important. If you don't have Anxiety and depression before you have autonomic nervous system dysfunction, autonomic nervous system dysfunction can cause anxiety and depression. A lot of patients feel different, feel left out, feel like they're missing things. Education and ongoing support, this is very, very crucial. So education on the chronic nature of autonomic nervous system dysfunction, emphasize emphasizing that it really is hydration, lifestyle changes, symptom management. I have all of my patients in the PA clinic sign up for MyChart. I call everyone 2 to 3 weeks after seeing them, sometimes 4 weeks, just to main, uh, just to see how they're doing, see how things are going. And then I have a patient come back and see me if we have medication. So if I prescribe a medication, I'm gonna want to see a patient back, um, to get Electrolytes and other uh things, um, especially if they're on fludrocortisone because it can mess with your electrolytes. So we get a CMP on those patients and um other medications as well, just to make sure that everything is, is going well. I get a lot of my chart messages from my patients and um my nurses really help with the with with a lot of those. Um, And then, like I said, those follow up phone calls. Supportive care. So, like I said, psychological support, physical therapy, school accommodations. I have, I think, 5 different letters that I can help a patient, um, with to send to school, send to, um, whoever, college, work, all of those kinds of things. And then a multidisciplinary approach. Many patients benefit from seeing a lot of different, a lot of different, um, uh, subspecialties. So cardiology, neurology, rheumatology, allergists, GI, psychologist, psychiatrist. Prognosis of autonomic nervous system dysfunction. Varies depending on what is the cause. So many cases have a very good long-term prognosis, but it's not something that you can just drink your fluid, eat your salt for a couple months and things are gonna be better. Um, if you have autonomic nervous system dysfunction, it really is a lifelong change. Lots of times, um, after a patients through puberty, they have improvement, so improvement with age, improvement when they are out of their teenage years, and then it really can be dependent on underlying causes. This is our PA clinic. See if this will pull up. I hope that everyone can see this, but if, um, so as you can see here, our PAD clinic, we're providing care to patients with those symptoms of autonomic nervous system dysfunction, including dizziness, lightheadedness, tachycardia, and you're fainting and fainting. All of my patients that come in, get the 5 to 10 minute stand test. If you're coming to see a cardiologist, you're gonna get a baseline EKG. If there's a lot of tachycardia, a lot of palpitations, we do a 24 to 48 Holter monitor, and then some of my patients that have prolonged issues, prolonged syncope, we do do an event monitor. Some of the patients get an echocardiogram, kind of depends on the lab tests, and then as you can see here is my collaborating physician, Doctor Sumsky, and myself. Now, let me see if I can click out of this. OK, I hope that everyone can still see me. And then I see patients um in my PAT clinic. I see patients here at Saint Louis Children's Hospital. And this is the phone number, the physical phone number to come and see us here um at the PAT clinic just to call our office at the, as you can see here. I physically see patients at Saint Louis Children's Hospital, and then I see a bunch of patients at the specialty care clinic in South County. Um, there are a couple of our cardiologists that that see patients at some of those other outreach clinics, but specifically the PAD clinic, like I said, is both at here at the main campus of Saint Louis Children's and in South County. My references. Other helpful resources. So I am getting ready to go to Santa Barbara on Monday. I'm a part of the American Autonomic Society, and we have a yearly conference. So I'm going this coming week to learn a lot more about autonomic nervous system dysfunction, and a lot about um our pediatric patients. Dysaudiomia International is a great website that you can go on just to learn more about autonomic nervous system dysfunction, and they have some of those um letters for school. Standing up to POTS is a very good organization as well, and then just learning more about pots, learning more about autonomic nervous system dysfunction, uh, on my heart. And that is it. Thank you, Shannon. Uh, does anyone have any questions for her this morning? You can unmute or put them in the chat box. If not, I will put in your QR code. Thank you so much for everyone's time. I really do appreciate you all listening to me this morning. I am very, very passionate about autonomic nervous system dysfunction, and I am more than happy to talk to anyone at any time, um, or see your patient in clinic. Mm. I have issues getting that QR code in there. I apologize. Do you think I have to stop sharing? I think so. I'll take control back. Yes, sorry. OK. No, you're good. So. Shannon, do you happen to have access to your QR code? I do not have access to my QR code. I cannot get it in. Is there any way to just put it in the chat? That's what I was trying to do. Yeah. Yeah, so Madison didn't even send me the QR code. Yeah I try to send it to me and or do you have it at all? And then I can try to, it won't let me put it in our chat box, but yes, I do have it. You know, it's in the email that uh was sent as a reminder. Oh, good. People have the email, that would probably take care of it. Since everybody's hanging in there, so if I have a patient that comes in and we do the down for 10 minutes and up and I have a um. Uh, at 5 minutes, heart rates over, you know, 40 above baseline, uh, maybe even symptoms, is that satisfactory if I take a good history and nothing else is going on, to just go ahead and treat without doing any other studies. Um, I think that it's satisfactory as long as the patient, um, then starts having relief, um, from those, you know, non-pharmacologic things. So, um, I don't think you necessarily, I mean, if they're not having chest pain with activity, um, they're not having significant cardiovascular symptoms. It's something that you can, yeah, definitely try to do really increase your fluid, really increase your salt. Give it a few weeks, see if they have um symptom relief from that. I don't think you have to jump and get a a a bunch of, you know, cardiac, um. Uh, cardiac, uh, exams. Oh, I see, I see, uh, the QR code here in our chat. I'm gonna put um my email in the chat as well, if anyone, I mean, you can email me at any time. That's the one thing I don't think that I uh I put a ah in my. In my talk, so. All right, thank you. So when I was able to get that QR code in there. I still am not um able to let me put it in, but I appreciate everyone being on. Yes, thank you so much. And have a good rest of your day. Take care, everyone. Thank you so much.
