# 28YOM, Syncope



## Melclin (Aug 23, 2011)

I've been wanting to post scenarios regularly even if they aren't noodle scratchers. Just everyday common conundrums so people can compare notes and students/newbies can have a crack without fear of retribution. This is one of those scenarios.

Called to a 28YOM Unconscious/fainting - conscious/breathing/no bleeding. 

Approx 15 minute response time.

O/A- You are lead by a calm looking woman in her late 20's to a young bloke lying L lateral, covered with a blanket, in a reasonably cramped corridor on a cold wooden floor. 

He is conscious and talking to you. Him and his wife were having an argument when she observed him to drop to the floor followed by 10-20 seconds of upper limb rigidity and looking like he was gasping. She is unsure about any other seizure activity when asked. The pt then experienced approx 5 mins of drowsiness and confusion per the wife and but the pt contests that saying he just felt really tired but does not remember the shaking limbs or falling to the ground. Asymptomatic after 5 mins. 

O/E BP: 110/60. HR 80. RR 16. Temp: 36.5 (97.7). BSL: 4.9 (90). SpO2 98% GCS 15.

HEENT/Neuro: PEARL, Normal eye exam (movement/acuity). Normal mental status per wife, alert, maybe a little sombre. Nil head/neck pain/c-spine pain on palpation. Normal movement of facial muscles, normal speech. Head/neck is atraumatic.

Trunk: Chest is clear and equal. Equal exansion, no distress/accessory muscles evident. Heart sounds normal. Nil, chest pain/abdo pain, palpitations, SOB or nausea. Abdomen is soft and atraumatic. 

Limbs/Extremities: Hands are cold and reasonably pale. Equal/normal strength/sensation in limbs. 

*Medical Hx.*
-When asked, pt has a hx 8 months previous of syncope after a bowel motion while he had gastro, investigated in the ED. Had and ECG done at the time and they though he may have had a heart attack. He knows nothing more about this. 
-Asthma, well controlled, infrequently uses puffer. 

Generally fit and well of late. Normal bowel motions/micturition.

*Meds*
Albuterol

*Allergies*
Penicillin 

*Social hx*
Nil drugs, drink infrequently. Works as a electrician. Is currently at the house you've been called to visiting relatives for the weekend. They've had a nice time and the argument with the wife was about whether or not they could afford to stay another few days. 

ECG shows ST elevation in leads II and III. I'll post the strip in a few hours when my printer starts working.


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## Melclin (Aug 23, 2011)

Complains only of nausea. Dizziness on standing with no changes in orthostatic vitals.


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## Melclin (Aug 23, 2011)

...and here is the strip





Sorry about the time lapse presentation.


COME ON, THIS ONE IS FOR ALL COMERS. THE "BE NICE" RULE IS ABSOLUTE IN THIS THREAD. 31 VIEWS SO FAR, YOU ALL HAVE OPINIONS.

Lets add too it. 

The choice of hospital is a small advanced care facility 10 mins away. Can do most basic blood work, x-ray and CT available currently with gen med and gen surg admissions. Not specialty surg, no cath lab/angio, no speciality admissions. OR a hospital 30 mins away with most services except neuro surg, cardiothoracic surg. OR chopper to a hospital that has everything.


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## abckidsmom (Aug 23, 2011)

Your strips are very interesting.  Is that in diagnostic mode?  Like that's a real 12-lead, sort of?

I am not convinced of the seizure angle.  I lean more toward some cardiac issue causing the syncope.  Even with gastroenteritis, 28 yo guys shouldn't be having syncopal episodes in the bathroom.

Plus, I'm more convinced of his cardiac insufficiency by the way he stayed in the floor for all this time before arrival.  I think that's a key clue to his Sick level.


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## abckidsmom (Aug 23, 2011)

I would take him to the 30 minutes away hospital.


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## truetiger (Aug 23, 2011)

15 lead?


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## Melclin (Aug 23, 2011)

Okay, interesting angle ABC. Whats your differential? If you want to question his still lying on the floor, you find that his wife has taken a recent first aid course and told him to stay put (its exceedingly common around here).

Sorry tiger, no 12lead at the basic level here. Only for ALS. Even there, I think its under utilised. I will post 12 lead results in the conclusion, but I have to confess, I lost the photo copy of the hospital 12 lead/12v4R so I won't be able to post the actual images.


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## truetiger (Aug 23, 2011)

I'm voting cardiac too. Possible inferior with RVI?


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## usalsfyre (Aug 23, 2011)

Without 12 lead we're going to the cath lab by default. I'm not sold a non-diagnostic 3-lead is good enough to call a STEMI, but the presentation certainly sets off alarm bells.


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## silver (Aug 23, 2011)

truetiger said:


> I'm voting cardiac too. Possible inferior with RVI?



A shot in the dark for a differential, but a possible takotsubo cardiomyopathy. Patient presents with ST elevations like an AMI at a young age, syncope, and was in a stressful situation. Doesn't exactly explain why he was on the floor for so long though...


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## thinkABC (Aug 23, 2011)

Some kind of cardiac event on the right side affecting perfusion to the SA node?  A coronary artery spasm or even a thrombus?  

Hence he dropped into a junctional or other escape rhythm for a couple of seconds, and a lack of brain perfusion caused the seizure/loss of consciousness?  My other guess is a TIA; possibly that same embolus found its way to the heart and is causing the ST elevation?

This fool needs rapid transport to a cath lab.  Can't give nitro, can't give morphine.  Aspirin, O2, diesel.


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## Aprz (Aug 23, 2011)

Heh, I feel pretty crappy about doing scenarios. I hope I don't disappoint!

My guestimate of the QTc and his age makes me think this is an STE-mimic like BER. After talking with Silver about Tako Tsubo, it does sound like it, but it's not very common which makes me think this isn't it (since you said it was common). I'd try ruling out STE-mimics, ask if his family has any cardiac or seizure history.

Her description sounds like a post ictal phase to me too.

So I'd be going with seizure with BER, lol. The ECG is just there to throw us off, haha.

I think I'd just transport to the facility 10 minutes away and monitor the ECG for changes.


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## truetiger (Aug 23, 2011)

With his previous cardiac history, current episode, and ekg findings, it would be irresponsible to take him to an inappropriate facility. He needs a hospital with a cath lab.


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## silver (Aug 23, 2011)

Aprz said:


> Heh, I feel pretty crappy about doing scenarios. I hope I don't disappoint!
> 
> My guestimate of the QTc and his age makes me think this is an STE-mimic like BER. After talking with Silver about Tako Tsubo, it does sound like it, but it's not very common which makes me think this isn't it (since you said it was common). I'd try ruling out STE-mimics, ask if his family has any cardiac or seizure history.
> 
> ...



or maybe it wasnt benign
http://www.nejm.org/doi/full/10.1056/NEJMoa071968


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## fast65 (Aug 23, 2011)

I'm leaning more towards a cardiac issue as well, with his history and the EKG findings we have right now, I'm gonna start working down the cardiac pathway and dig into that a little deeper. At this point, this gentleman is going the hospital with a cath lab.


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## Melclin (Aug 24, 2011)

He was on the floor because his wife had told him to stay put. He was perfectly capable of moving. Is this not a common finding where you guys work? Some combination of hearsay/old wives tales/first aid certs seem to conspire to to bring forth a bystand/family memeber who keeps the pt on the ground/lays them down, +/-legs in the air, +/- a blanket. I wouldn't read too much into it. 

Dig deeper in what way?

Nil exercise intollerance hx. Never has chest pain/palpitations/dizziness unusual SOB. Nil arrythmia hx. Mum and dad are both alive and well in their late 60's, nil cardiac or stroke hx on either side. The only cardiac family hx that he knows of is an elderly uncle who is due to a valve replacement. He has never been seen for anything to with his heart. He does not and has never smoked. He is caucasian.

The only thing that jumps to his mind was when he fainted on the toilet that time eight months ago, when he got to the ED he says "there was a big pannic for a moment that he was having a heart attack, then nothing happened", they told him he was fine, and they sent him home that day.

More to come.... I just got a job. BRB/


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## usalsfyre (Aug 24, 2011)

Enough of an old wives tale our dispatch repeats it in prearrivals :facepalm:.


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## Melclin (Aug 28, 2011)

I did mean to post the conclusion a little earlier than this, but I've spent the weekend on a wine tour. White people problems are the worst.


So some interesting thoughts in this thread and it certainly made me go back and re-evaluate the way I went about this job. 

The ED docs thoughts were that this was a seizure. She thought the story was clear enough to go down that path. His 12-lead showed pretty much universal ST - elevation. The ED doc was not phased at all. He remained asymptomatic the whole time. Troponin negative. He was discharged about 4 hours later with neuro outpatient follow up. 

My thinking:  I didn't think the wife's story was clear enough to definitely think seizure. I thought vasovagal brought on by the exertion of an argument, with a few twitches when he hit the ground. The description of what sounded roughly like a post ictal period was still troubling to me though. RE the ECG that the ST elevation must have been benign early re-polarisation. My understanding is that it is usually seen in the anterior leads and that it is reasonably rare in the inferior leads as in this case, but he was particularly fit and it seen more in people who are particularly fit right? Anyway the thing that sealed the deal from my perspective was this story about the ED panicking a little at first when they did an ECG last time and then nothing happening. To me that said a nurse has seen the same elevation I saw and thought MI, its gone to the consultant who has then shaken the head. Perhaps I put to much weight on this assumption. This seemed more likely than a particularly fit and healthy 28 year old without a single risk factor or symptom (baring some syncope/?seizure that is more easily explained in other ways), having an MI. So I took him to the local hospital, and as it turns out, I was right in the sense he wasn't having an MI, but I'm a bit concerned about the decision making process that got me there. Maybe there are some factors that are harder to communicate in case studies, but it concerns me that a lot of people here whose opinions I really respect would have taken this guy to the cath lab hospital. 

I don't know what this business is about young people fainting being a concern is though. We see literally hundreds of perfectly healthy young people who get drunk/dehydrated/overexerted and take a turn at concerts and music festivals when I do events. I've got a bit of a tendency to have vagals myself, when I've had a few more beers than I should have and I try to do something excessive like run a mile to the kebab shop before it closes. 

I've since looked into it quite a bit more. It turns out (1,2) risk factors aren't a great tool for risk stratification even though they are commonly used in that process. Which kind of drilled a bit a whole in my not thinking MI.

Does anyone know if young people are more likely to have silent MI for any reason? I would have thought, if anything, they would be less likely. 

1) http://www.resuscitationjournal.com/article/S0300-9572(08)00540-6/abstract
2) http://www.annemergmed.com/article/S0196-0644(06)02402-4/abstract


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## MrBrown (Aug 28, 2011)

Brown thinks you are spot on mate, reckoned it was some sort of seizure too


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## truetiger (Aug 29, 2011)

I've seen a few cases in which a young male was having a stemi with no risk factors what so ever. These were caused by coronary artery spasms.


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## Aprz (Aug 29, 2011)

I'm running around my room with both my arms up shouting "I was right! I was right!" or at least the Doc agrees with me with the info provided.


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## Melclin (Aug 31, 2011)

truetiger said:


> I've seen a few cases in which a young male was having a stemi with no risk factors what so ever. These were caused by coronary artery spasms.



Definitely. There are a number of causes of MI in those age groups. You get a 18 year old snorting half his dad's salary, I can see.  And in the absence of thing like, having run a marathon or drug use...what is the likelihood. And on top of that what is the likelihood of it being essentially asymptomtic?




> I'm running around my room with both my arms up shouting "I was right! I was right!" or at least the Doc agrees with me with the info provided.



Haha, well done. See this is why I hate for EMTs or students to be too afraid of being yelled at by the paragods to have their say. More I say, MORE!


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