# 75 year old male syncopal episode.



## NYMedic828 (Apr 26, 2012)

75 year old male syncope x 30 seconds in bath tub witnessed by home aid.

No complaints prior to acute occurrence of syncope. He had a syncope prior in the week which was undiagnosed at hospital.

Upon arrival pt is concious sitting in bath tub. States he feels "alright."

We move patient out onto our chair and go right out to the vehicle. (too tight to work inside)

Patient at this time in baseline mental state as per family.

Initial vitals

BP 111/67 (lying semi-fowlers)
HR 100
RR 18
SPo2 98%
3 ECG - Afib
12 ECG - unremarkable.

About 3 minutes after we get into vehicle HR speeds up to 130-150 ventricular rate (afib) and stays there for the remainder of care.

Patient denies any change in his condition but he has severe dementia as is.

New vitals

BP 97/60 (legs elevated)
HR 130-150
RR 18
SPo2 100%
3/12 unchanged still afib.

Patient history:
Dementia
Parkinson's
HCL
HTN



Go.


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## Aidey (Apr 26, 2012)

His rate is poorly controlled, he probably needs his meds adjusted.

Also, why legs elevated? Trendelenburg has been debunked more than backboards have.


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## NYMedic828 (Apr 26, 2012)

Aidey said:


> His rate is poorly controlled, he probably needs his meds adjusted.
> 
> Also, why legs elevated? Trendelenburg has been debunked more than backboards have.



Because NYC still advocates all of that. 

I just lay em down... Partner gets a bit anal with how his patient looks entering the ER.


He had no history of afib, hence no meds for it to be adjusted.


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## FLdoc2011 (Apr 26, 2012)

Hemodynamically stable so not much to be done pre-hospital or emergently.   Could certainly be new onset afib and needs a certain basic workup done in hospital.     

Can always consider  vaso-vagal and orthostasis from dehydration or autonomic dysfunction (from parkisons) though other serious things need to be ruled out.

Any murmurs on exam?


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## NYMedic828 (Apr 26, 2012)

FLdoc2011 said:


> Hemodynamically stable so not much to be done pre-hospital or emergently.   Could certainly be new onset afib and needs a certain basic workup done in hospital.
> 
> Can always consider  vaso-vagal and orthostasis from dehydration or autonomic dysfunction (from parkisons) though other serious things need to be ruled out.
> 
> Any murmurs on exam?



I put it down as a possible new onset afib.

I am reluctant to say that heart sounds aren't common practice here and as much as I wish I did, I wouldn't know what I'm listening for apart from the standard healthy heart sound. Which I guess hearing any deviation is a start.


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## EMT91 (Apr 26, 2012)

Possibly a brain hemorrhage?


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## STXmedic (Apr 26, 2012)

EMT91 said:


> Possibly a brain hemorrhage?



Thought process behind this?


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## Handsome Robb (Apr 26, 2012)

EMT91 said:


> Possibly a brain hemorrhage?



edit: Poetic took the words right out of my mouth.

Unless I missed it, no unilateral weakness, deficits, fixed gaze, blown pupil, slurred speech, headache and/or seizure activity. Bleeds tend to have a pretty unique look to them, in my experience, but there always are abnormal presentations. 

Seems pretty cut and dry to me but take that with a grain of salt. Arrhythmia causing drop in BP leading to the syncopal episode.

Any changes with fluids? Probably a long shot but no cardizem? Doesn't seem like urban services carry it too often, we don't. With the syncope + lowish BP in trendelenburg's I'd call him symptomatic. Not to the point of cardioversion though unless he deteriorated even further. Plus I couldn't sedate him unless I got his SBP up above 100 mmHg with a fluid bolus.

I'm not really a fan of the vaso-vagal since he was in the bath but if he sat up for the aid to wash his back then was corrected when he passed out and fell flat-ish again it definitely is possible.


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## Aidey (Apr 26, 2012)

Depending on the temp of the bath it could still be vaso vagal, especially if the bath was drawn and then he got into it.


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## NYMedic828 (Apr 27, 2012)

Aidey said:


> Depending on the temp of the bath it could still be vaso vagal, especially if the bath was drawn and then he got into it.



It was a sponge bath :lol::lol::lol:



NVRob said:


> edit: Poetic took the words right out of my mouth.
> 
> Unless I missed it, no unilateral weakness, deficits, fixed gaze, blown pupil, slurred speech, headache and/or seizure activity. Bleeds tend to have a pretty unique look to them, in my experience, but there always are abnormal presentations.
> 
> ...



Didn't give him any fluid since technically he was fine. We have a very clear protocol for what is unstable and what is stable afib. 

We actually do have a cardizem protocol, but we don't have cardizem anymore. They supposedly want to get it back.

My friend suggested the possibility of maybe he didn't even syncopize, rather he fell asleep but I he was actively being bathed so I don't know about that.


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## FLdoc2011 (Apr 27, 2012)

PoeticInjustice said:


> Thought process behind this?



Unlikely like was already mentioned but chances are ED is going to scan his head anyway to rule out a hemorrhage.   Especially if he had syncopal episode a week ago (hit his head then?), in an elderly it's a perfect setup for a slow subdural.  Again, not as likely if normal exam but I've had a bunch of bleeds with normal exam.   In any case the ER will rule it out.

UTI is also on my differential.  In elderly a UTI can pretty much cause anything.


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## EMT91 (Apr 27, 2012)

PoeticInjustice said:


> Thought process behind this?



The primary reason was the drop in BP, despite a history of HTN,


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## Aidey (Apr 27, 2012)

Why does the drop in BP lead to you to suspect a brain hemorrhage?


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## NYMedic828 (Apr 27, 2012)

Drop in BP I usually suspect cardiac/inbleed first depending on heartrate?


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## EMT91 (Apr 29, 2012)

Aidey said:


> Why does the drop in BP lead to you to suspect a brain hemorrhage?



Because of the prior syncopal episode.


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## Aidey (Apr 29, 2012)

Huh? What you are saying doesn't make a lot of sense. 

Low BP is generally not a sign of an brain hemorrhage. The increased inter-cranial pressure that can develop in brain bleeds actually leads to increased BP, not decreased. I can also think of about 20 things that cause syncope that are more likely in this case than a brain hemorrhage. As was mentioned above, aside from the syncope the pt has no symptoms of CVA or other neurological insult.


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## EMT91 (Apr 29, 2012)

Aidey said:


> Huh? What you are saying doesn't make a lot of sense.
> 
> Low BP is generally not a sign of an brain hemorrhage. The increased inter-cranial pressure that can develop in brain bleeds actually leads to increased BP, not decreased. I can also think of about 20 things that cause syncope that are more likely in this case than a brain hemorrhage. As was mentioned above, aside from the syncope the pt has no symptoms of CVA or other neurological insult.



I see. Well, its a good thing I posted my idea here, instead of in the field, its a learning process, and I am glad that I am able to learn. I just got mixed up.


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## Akulahawk (Apr 30, 2012)

Given what is known about the patient's history, and the presence of atrial fibrillation on the EKG,and the fact that this patient is in his 70s, and has been SBP of approximately 110 at best, I think this patient's syncopal episodes are from a combination of dehydration and an arrhythmia, specifically atrial fibrillation, interacting. I think this patient does not have a whole lot of intravascular volume and when his atrial fibrillation has a more rapid ventricular response, I think we see a drop in cardiac output that is sufficient enough to cause him to have a syncopal episode.

I could be very wrong, but based upon the information that I see posted here, that is what I think is the issue.


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## mycrofft (Apr 30, 2012)

Comment above: atrial fib had not yet been DX'ed. 

Again and again, back to basics. Was the pulse weak or strong, regular or irregular, irregularly or regularly irregular (strength and rhythm of pulses)? 

Change in character of the pulse coupled with prompt drop of BP despite increase of pulse rate suggests ineffective pulses. If the pulse is irregularly irregular in rate and strength, atrial fib is very likely but not a diagnostic lock. (Even if pulse was regular in rhythm and either minimally or not irregular in strength, it could still be a-fib; ineffective fluttering could be impalpable. EKG is called for if available, and apical pulse with possible manual correlation with radial pulse could be educational and of use).

As for volume deficit, the elderly are prone to that, don't discount it. Ask about possible additional volume loss (vomiting, diarrhea, diuretic meds)  and signs of bleeding (purpura, tarry or bloody stool, other signs of internal bleeding).


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## Localmotion34 (May 4, 2012)

The fact that he has Parkinson's and "dementia" may lead one to take a close hard look at his meds.  Generally Parkinson's patients are on Sinemet dopaminergic agonist therapy, dementia patients are on acetylcholinesterase inhibitors, and severe dementia patients are usually on neuroleptics.  

This is the wonderful world of polypharmacy we live in, along with Physicians diagnosing "dementia" as if they were 3rd year medical students.  

Parkinson's Disease > 2 years followed by the emergence of dementia  = Parkinsons Disease Dementia.  Parkinsonian symptoms emerging closely spaced in time with dementia = Dementia with Lewy bodies.  

Either dementia patient generally should not receive neuroletpics, but we all know they do.  

Anything like this based on this type of patient I assume is it a medication adverse event until proven otherwise, unless there are focal neurological signs present.  

Did he recently start an acetylcholinesterase inhibitor for dementia, or did he recently discontinue one abruptly? Or was he on an antipsychotic?


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## mycrofft (May 4, 2012)

Good one Local!


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## Handsome Robb (May 5, 2012)

Localmotion34 said:


> The fact that he has Parkinson's and "dementia" may lead one to take a close hard look at his meds.  Generally Parkinson's patients are on Sinemet dopaminergic agonist therapy, dementia patients are on acetylcholinesterase inhibitors, and severe dementia patients are usually on neuroleptics.
> 
> This is the wonderful world of polypharmacy we live in, along with Physicians diagnosing "dementia" as if they were 3rd year medical students.
> 
> ...


I learn something new all the time on here! Great post Local, keep them coming please!


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## mycrofft (May 5, 2012)

Local's remark tells us why we need to call medical control once in a while, and it better not be in New Delhi.


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