# 60 y/o female syncipal episode



## amoose55 (Aug 19, 2012)

You (a Paramedic), and your EMT partner are an ALS truck and are toned out to a medical call for a 60 y/o female who had a syncopal episode in her kitchen. Upon arrival 10 minutes after being dispatched (you are rural ems), firefighter tell you she is seated on the floor and is stable. No trauma to patient from GLF. As you enter the kitchen, you see the pt who looks stable but says she "passed out and and feels really dizzy." She has a history of High Blood Pressure and SVT. You go to feel for a radial pulse but it is very thready and you cant get an accurate Heart Rate.  You move her to the stretcher and into the back of the ambulance.  You attach her to the monitor and see a juntional rhythm at a rate of 42, pt stills look good, just very cold and clammy.  12 LEAD reveals nothing of concern for MI just a juntional rhythm of 38-42.  BP is 88/42, 16R, 88 BGL.  Pt says that she still feels dizzy, cold and a little nauseous  What would you do in this situation as the Paramedic in charge? Closest hospital is 30 min away.  Pt was also a former drug user and all her veins were shot, pt has been clean for 20 years.


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## shiroun (Aug 19, 2012)

amoose55 said:


> You (a Paramedic),and your EMT partner are an ALS truck and are toned out to a medical call for a 60 y/o female who had a syncopal episode in her kitchen Upon arrival 10 minutes after being dispatched (you are rural ems), firefighter tell you she is seated on the floor and is stable.No trauma to patient from GLF.As you enter the kitchen, you see the pt who looks stable but says she "passed out and and feels really dizzy."She has a history of High Blood Pressure and SVT.You go to feel for a radial pulse but it is very thready and you cant get an accurate Heart Rate. You move her to the stretcher and into the back of the ambulance. You attach her to the monitor and see a juntional rhythm at a rate of 42, pt stills look good, just very cold and clammy. 12 LEAD reveals nothing of concern for MI just a juntional rhythm of 38-42.: BP is 88/42, 16R, 88 BGL. Pt says that she still feels dizzy, cold and a little nauseous What would you do in this situation as the Paramedic in charge? Closest hospital is:30 min away.Pt was also a former drug user and all her veins were shot, pt has been clean for 20 years.



WHY ARE THERE SO MANY CENSORS. My head hurts.

Anyway, no trauma, thready pulse, low BP, good respirations. I'd really just monitor and go. Give her a blanket or something to warm up (take a temp first if possible), if ALS was present they might administer a bolus, althought with poor veins that could be..interesting. Maybe it would be done i/o. Heart-rate is a little low, but I wouldn't be too worried about it. ALS might administer a small dose of atropine, or something to bring it a little up, but that's all I can think of. 

Also, a side note, you CAN get an accurate heart rate. If you aren't able to at the radial, go for the carotid, and if that isn't working too well then put your stethoscope on her chest and count it out for a minute*
* - Do that in the ambulance, a lot of time to waste in a house.

I'm sure other people will give you more input, especially from an advanced-providers perspective, I just wanted to give my two cents.


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## DrankTheKoolaid (Aug 19, 2012)

First get her back into a supine position and not sitting up.  Prepare for pacing.  Junctional is just that, Junctional.  Very unlikely she is going to respond to Atropine.  Get line, give analgesic, sedation and pressors in that order to maintain a MAP of 60.  Fluid as tolerated and based on lung sounds.  Though even rales will not keep me from administering more fluids if needed, then you just play the titrate the head of the bed game VS MAP.  Other then that a slow stroll to a Hospital with implanted pacemaker capabilities.

No you say 12 lead is negative for MI but what about HyperK.  If i was suspicious of it i would go down that route with CA++, albuterol and NAHCO3


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## amoose55 (Aug 19, 2012)

Sorry about the censors. Using my iphone. Negative on hyperK.


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## Anjel (Aug 19, 2012)

I would go with IV and fluids. See if I can get the pressure up a tad.

I would give Atropine just because I have to before I can pace *Only time we can bypass Atropine first is with heart transplants and high degree heart blocks*. But I would do so while my partner was applying the pads. 

And the rest just as Corky said. Bottom line she isn't perfusing well. Time to get the heart rate and BP up.


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## FLdoc2011 (Aug 19, 2012)

Corky said:


> First get her back into a supine position and not sitting up.  Prepare for pacing.  Junctional is just that, Junctional.  Very unlikely she is going to respond to Atropine.  Get line, give analgesic, sedation and pressors in that order to maintain a MAP of 60.  Fluid as tolerated and based on lung sounds.  Though even rales will not keep me from administering more fluids if needed, then you just play the titrate the head of the bed game VS MAP.  Other then that a slow stroll to a Hospital with implanted pacemaker capabilities.
> 
> No you say 12 lead is negative for MI but what about HyperK.  If i was suspicious of it i would go down that route with CA++, albuterol and NAHCO3



Why the analgesics and sedation?   Unless you were referring to pacing.


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## DrankTheKoolaid (Aug 19, 2012)

FLdoc2011 said:


> Why the analgesics and sedation?   Unless you were referring to pacing.



Yup, in case I ended up pacing.


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## Handsome Robb (Aug 19, 2012)

This doesn't scream pacing at me. It most definitely has the potential to go that way quickly if she doesn't respond to other measures but I'm not going to jump straight to it. If you can't get a line on her arms try an EJ or start looking on her legs, she needs a line. I'm not going to jump to an IO but if she crumps and I don't have access I'm not going to **** around trying to get a line on her. 

Like everyone else said, positioning is important and she needs fluids. Atropine as a trial but I'm with Corky on it probably not working. Give it a fighting chance though, not just 0.5 mg then quit. I'm not advocating going all the way to your max dose but 1-1.5 mg seems appropriate. 

Her MAP is 57.3...not enough even if she is mentating well so something needs to change. 

Cliff notes:
*GET A LINE, you have 30 minutes to the ER that's a lot of time and it's high on the priority list. EJs, feet, biceps whatever you can find. Get 2 if you can. Worst case IO + a bit of lidocaine (20mg should work for nana) is a strong possibility.
*Atropine (probably wont work but might as well try it)
*Fluids. Seems cardiogenic not hypovolemic but lets see if Mr. Starling will help us out.
*If she deteriorates or her pressure is refractory to the first choices pacing plus a dash of fentanyl then worry about sedation when her pressure is better controlled.
*Pressors as a last ditch, dopamine is all I carry, I'd start at 5 mcg/kg and work up from there. 

I wouldn't be going code to the hospital just yet but if she goes the wrong direction it may be appropriate if you hit traffic.

Random question. She has a history of HTN. Are we 100% sure it's junctional and not just sinus brady? What meds is she on for the HTN? Any Beta Blockers? Any chance grandma accidently double dosed herself? *cough* glucagon *cough*


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## DrankTheKoolaid (Aug 19, 2012)

Disregard


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## amoose55 (Aug 20, 2012)

What I did was got an IV, Atropine raised her heart rate to 56.  Just gave her fluids and her BP went up to 112/68.  The doc said it was good that I didn't pace as he thought it wouldn't have worked. I did put the pads on her first just as a precaution. He gave her some more atropine while I was in the room and she immediately went down to 28.  Scared the Dr a little bit so I wasnt really able to ask the Dr any questions unfortunately.  When we left the RN said the Dr. put in a trans-venous pacer and she was stable with a heart rate of 78.


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## DrankTheKoolaid (Aug 20, 2012)

amoose55 said:


> What I did was got an IV, Atropine raised her heart rate to 56.  Just gave her fluids and her BP went up to 112/68.  The doc said it was good that I didn't pace as he thought it wouldn't have worked. I did put the pads on her first just as a precaution. He gave her some more atropine while I was in the room and she immediately went down to 28.  Scared the Dr a little bit so I wasnt really able to ask the Dr any questions unfortunately.  When we left the RN said the Dr. put in a trans-venous pacer and she was stable with a heart rate of 78.



What did he mean by saying pacing wouldnt work, when he did exactly that?  Thats makes no sense whatsoever.


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## Handsome Robb (Aug 20, 2012)

Transvenous vs transcutaneous maybe? In clinicals I had a guy who's K++ was 8.75 and we couldn't get capture even with the energy maxed out.


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## DrankTheKoolaid (Aug 20, 2012)

NVRob said:


> Transvenous vs transcutaneous maybe? In clinicals I had a guy who's K++ was 8.75 and we couldn't get capture even with the energy maxed out.



Yeah I know hyperK and Hypoxia are 2 reason for poor mechanical capture, but this patient was neither.   I'm just curious what the MD was meaning when he said that.  He must have seen something else that maybe he didnt verbalize to the OP.


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## amoose55 (Aug 23, 2012)

It really struck me odd to when he said that to me. I have been asking around and have not gotten a good answer but what you guys have been throwing out. Negative on hyperK.


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## fz6 (Sep 9, 2012)

*paradoxical bradycardia*

Could the doc have given the atropine too slowly causing paradoxical bradycardia?


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