# Near Syncopal Episode



## LAS46 (Nov 24, 2010)

EMS is called to a "Wellness Center" (it would prove to be a chiropractor's office) for a 20-year-old male with a near syncopal episode.

On arrival the patient is found sitting in a chair with his head between his legs. He is pale and diaphoretic and appears acutely ill.

The patient's chiropractor states that he was adjusting the patient's spine when the patient complained that he didn't feel well.

The chiropractor sat the patient down on the end of the exam table and the patient suddenly "went limp."

The chiropractor caught the patient and laid him down flat. The patient recovered, sat up, insisted on standing, promptly "went limp" again and was placed in a chair.

The chiropractor contacted 911.

Past medical history: "Back problems"

Medications: Vicodin, Skelaxin, Flexeril

Vital signs are assessed.
RR: 18
Pulse: 56
BP: 92/48
SpO2: 99 on RA
BGL: 118

The patient denies chest discomfort. He admits to nausea but has not vomited.

Breath sounds are clear bilaterally.

A 12-lead ECG is captured.







And another.






You are 15-minutes from the local non-PCI hospital and 45-minutes from a STEMI Receiving Center.

How would you treat this patient and why? What do you think your field DX would be?

(Click on the ECG pictures to enlarge them.)


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## Melclin (Nov 25, 2010)

You really should mention this is a repost from Tom Bs article at EMS1.


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## LAS46 (Nov 25, 2010)

Yes sorry I meant to put this information in. Here is the Authors info.

EMS 12-Lead
by Tom Bouthillet

Original was post on EMS1 on Nov. 21



Melclin said:


> You really should mention this is a repost from Tom Bs article at EMS1.


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## Chimpie (Nov 25, 2010)

Do you have a link to that, please?


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## LAS46 (Nov 25, 2010)

*Link To Original*

Here is the link to the post:

CLICK HERE


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## gfblanco (Dec 3, 2010)

As a BLS I would go ahead and determine him ALS. Expose and do a rapid trauma assessment, with spinal consideration. Put him on a backboard as this is a Load and Go situation. In the back I would recheck his LOC and ABCs, get a set of vitals and if ALS is not there yet, perhaps plan an intercept. While he was back there, I would put him in Trendelenburg's, do a detailed assessment and even as a measure of comfort, put a blanket over him. His vitals would get re-assessed every 5 minutes. 
I would appreciate a feedback on this since I'm taking my practical EMT-B on Wednesday!!! :3


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## Melclin (Dec 3, 2010)

gfblanco said:


> As a BLS I would go ahead and determine him ALS. Expose and do a rapid trauma assessment, with spinal consideration. Put him on a backboard as this is a Load and Go situation. In the back I would recheck his LOC and ABCs, get a set of vitals and if ALS is not there yet, perhaps plan an intercept. While he was back there, I would put him in Trendelenburg's, do a detailed assessment and even as a measure of comfort, put a blanket over him. His vitals would get re-assessed every 5 minutes.
> I would appreciate a feedback on this since I'm taking my practical EMT-B on Wednesday!!! :3



Don't you guys have to put 15 litres of O2 on everyone or something like that?


I think we can fairly safely say he's not having an MI.

On inspection of my "just in time learning resource" or iPhone medical apps (That's an actual term being thrown around in EMS academia at the moment. They need to work on their names), skelaxin can cause diziness, so that might come into it.

In any case, I think this is reflex mediated. IV and a bag just in case and as long as he remains GCS 15 we can hold off on ALS and go to the non-STEMI hospital I think.


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## Veneficus (Dec 3, 2010)

Melclin said:


> In any case, I think this is reflex mediated. IV and a bag just in case and as long as he remains GCS 15 we can hold off on ALS and go to the non-STEMI hospital I think.



I think the bigger question is is it a nervous issue, toxic issue, or a cardiac origin of the lack of reflex?

Or of course a combination of all 3?

Pain meds with dialated myopathy with nerve damage from manipulation? 

I really love the alternative medical industry. They will be paying the bills for a long time.


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## gfblanco (Dec 3, 2010)

Melclin said:


> Don't you guys have to put 15 litres of O2 on everyone or something like that?
> 
> 
> I think we can fairly safely say he's not having an MI.
> ...



Well, I'm not allowed to do any IVs, not to mention that as a BLS provider, we wouldn't even have that in the truck. We are taught that if the pt loses consciousness, we have to get ALS.


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## Bieber (Dec 4, 2010)

All right, I'll give it a shot.  Still just a paramedic student, so feel free to tell me if I'm way off base.  


Well, I'm not ready to discount anything just yet, I need some more information first.  And yeah, he's pretty young and the most common cause of ST elevation is not an MI, but cool, pale, diaphoretic with ST elevation still makes me suspicious of an MI regardless of the age.

First of all, just what in the heck was going on today right before this started?  What was the chiropractor doing to this kid's back?  Was this his usual therapy?  How long has he been undergoing this procedure?  Any previous complications?

Was he feeling ill earlier today prior to this single incident and has anything like this ever happened to him before?  Any other recent weakness/dizziness, fever, cough, n/v, diarrhea, stool or urine changes?  Has he been drinking enough fluids?  Been out working in the heat?  Any new changes/additions/discontinuations of his medications?  Is he taking any recreational drugs?  Any other medical history?

Also, besides the weakness, nausea and near-syncopal episode, is he having any other complaints?  Any numbness/tingling in the hands or feet?  Are his neurovasculars intact and normal?  Any orthostatic changes?

Unless he's complaining of head/neck/back pain or trauma, I'm going to consider him medical and hold off on the LSB and collar.  I'm going to go with IV, monitor and O2 via NC for now.


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## Melclin (Dec 6, 2010)

gfblanco said:


> Well, I'm not allowed to do any IVs, not to mention that as a BLS provider, we wouldn't even have that in the truck. We are taught that if the pt loses consciousness, we have to get ALS.



Yeah, I realize that. Only the first line was directed at you. The comments after the double space were my thoughts about the case. 



Veneficus said:


> I think the bigger question is is it a nervous issue, toxic issue, or a cardiac origin of the lack of reflex?
> 
> Or of course a combination of all 3?
> 
> ...



Seems odd that it would be sudden onset like that if it were an issue of toxicity or cardiomyopathy _alone_, doesn't it? I can certainly see it being a combination. Of course we'll never know about the actual pattern of onset, because this was primarily an ECG interpretation exercise, but I picture it as a, "Now bit of pressure my Mr. Smith", "Yep, I'm ready", *snap*, "Ooops...Mr Smith?".

What makes you think DCM over other CMs?

Haha, indeed. I have a natropath friend who was talking about the differential for sudden onset chest pain (legit problems, not ... fouled humours), but was completely oblivious of any emergent cardiac origins.


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## Smash (Dec 6, 2010)

Melclin said:


> Haha, indeed. I have a natropath friend who was talking about the differential for sudden onset chest pain (legit problems, not ... fouled humours), but was completely oblivious of any emergent cardiac origins.



I think you are referring to an excess of blood and a lack of black bile.  Some cupping and maybe a poultice of chicken livers and rosemary should fix that infarct up in no time!

God bless the gullible, the crazy and the just plain dim, they'll keep us all employed forever!


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## Aidey (Dec 6, 2010)

Alex, I'll take Vagal response for 1000.  

Poorly executed adjustment of the neck could absolutely cause hyperstimulation of the vagus nerve, resulting in all of the patient's symptoms. As for the EKG, I'm almost 100% sure that is benign early repolarization, and something he has had for years. At 19 he may never have had an EKG done before.


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## Veneficus (Dec 6, 2010)

Melclin said:


> What makes you think DCM over other CMs?.



Age, and somekind of activity that likely caused his back problems.


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## exodus (Dec 6, 2010)

I'm thinking ortho hypo? Why not a 500 ml bolus and see how he feels from there.


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