# 65 y/o M Syncopal Episode



## MassMedic (Mar 12, 2013)

Dispatched in the middle of the night for a 65 y/o M who has just experienced two syncopal episodes. The patient states that he was having trouble sleeping due to nausea that had begun after eating dinner earlier in the evening. When he got up from bed to "make him self throw-up" he experienced his first episode (while walking) and fell down in his hallway outside his bathroom door. His son helped him to a chair in his bedroom where he experienced a second syncopal. He does not remember either episode (son is on scene and giving his account) and is now sitting in that chair. Vitals are as follows:

Skin: pale, cool, diaphoretic
Pulse: 64
BP: 80/60
LS: clear bilaterally
SPO2: 98% on room air
ECG: Sinus rhythm

"Mild" nausea is his only complaint. He has not been sick recently and other than high blood pressure has no prior medical history. He has no allergies and his only medication is lisiniprol for the HPN. After lying on the stretcher his BP goes up to 130/80. All other vitals, as well as complaint, remain static throughout transport.

Thoughts?


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## RocketMedic (Mar 13, 2013)

Hmm...any blood in stool, ascites, or edema?
Hows his ecg?
Dehydration this serious seems very unlikely. 
Too mucn lisinopril?


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## VFlutter (Mar 13, 2013)

Sounds like orthostatic hypotension. If there truly is no past medial history then medication induced would be my first thought but cardiac still needs to be ruled out. 

How long has he been on it? Any recent dosage changes?


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## MassMedic (Mar 13, 2013)

No blood in stool and he has not (and never did) actually vomit. He takes his lisiniprol every morning so last dosage was about 17 hours ago. He has been taking it for "a couple years" and no recent changes. He stated that he had "never passed out before". ECG showed a sinus rhythm.


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## VFlutter (Mar 13, 2013)

MassMedic said:


> ECG showed a sinus rhythm.



Totally normal ECG? No blocks, ischemic changes, hypertrophy?


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## MassMedic (Mar 13, 2013)

Yes, completely normal sinus rhythm - 12 lead showed nothing remarkable. I was at a loss as to what would cause the orthostatic hypotension (hence my posting here looking for ideas)


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## VFlutter (Mar 13, 2013)

MassMedic said:


> Yes, completely normal sinus rhythm - 12 lead showed nothing remarkable. I was at a loss as to what would cause the orthostatic hypotension (hence my posting here looking for ideas)



Old age. Tell him to pick up some Ted hose and take it slow getting up. 

Most syncope r/t orthostatic hypotension that gets ruled out is due to autonomic dysfunction


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## mycrofft (Mar 13, 2013)

Do orthostatic BP's. (I never read about them here. It's something of an art).

80/60 isn't a very good pulse pressure, I think. Recovered in the ambulance? Always question instrumentation as well as looking for other signs of physical malady.

EDIT: Lisinopril...was he having coughing jags?


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## VFlutter (Mar 13, 2013)

mycrofft said:


> Do orthostatic BP's. (I never read about them here. It's something of an art)



I do not really see the point in taking the time to correctly do orthostatic BPs in the field when they will be done in the ER.


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## mycrofft (Mar 13, 2013)

OK. I'm easy. 

Orthostatics  plus any attendant changes in pulse rate, regularity and strength might suggest dehydration versus pharmacy or autonomic issue, but since the interventions are mostly in the hospital, then get there.


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## Melclin (Mar 13, 2013)

Hydration status? Fluid intake in the past few days vs diarrhoea or vomiting. Recent frequency of urination? Skin turgour, mucosa, tongue furrowing, JVP? Recent exposure to environmental/behavioural fluid loss (heat, exercise, booze)? 

Haematemesis/coffee ground vomit, melena. When you say pale...bleeding pale or just fainted pale? Pale conjunctiva?  

Infective symptoms? Headache, myalgia, arthraliga, night sweats, productive cough, fever, rigours, increased urinary frequency/urgency, pain/stinging on urination, generalised weakness.

In the absence of beta blockade and in the presence of hypotension, his HR seems a little suspicious and maybe partly the cause of the BP/diaphoresis/pallor. Exposure to sick people/dodgy food? Maybe he's had a vasovagal from nausea/discomfort exacerbated by infection/dehyration/orthostatic changes. He wouldn't be the first. 

But the picture as presented and without further details is too suspicious for several things and warrants a trip to the ED. Syncope, especially in that age group is always worthy of suspicion. I'd give a little fluid dependant on his hydration status and a trip to an ED and I'd keep a good eye on his serial ECGs.



Chase said:


> I do not really see the point in taking the time to correctly do orthostatic BPs in the field when they will be done in the ER.



Assuming you take them to the ER. I think orthostatic vitals add to several other obs that inform treatment, your dx on which you proceed and the dx you hand to the triage nurse. 

That also assumes they will be done in the ER.


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## Hunter (Mar 13, 2013)

Orthostatic hypotension is probably behind the syncope. Possibly caused by passive lowering of his BP by his medications, he's been taking them for two years and it wouldn't be the first time someone's bp gets to a low resting pressure secondary to taking medications for a prolonged period of time. Like others have said, get em to the ER for further evaluation. I'm also suspecious of the ECG being NSR at that BP, I'd expect it to at least be a bit elevated after falling twice and with all the commotion going on.


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## mycrofft (Mar 14, 2013)

"But the picture as presented and without further details is too suspicious for several things and warrants a trip to the ED. Syncope, especially in that age group is always worthy of suspicion. I'd give a little fluid dependant on his hydration status and a trip to an ED and I'd keep a good eye on his serial ECGs."

Yeah, when Gramps loses consciousness I get sort of concerned too.


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## coolidge (May 26, 2014)

Old post, but I was curioius as to the patient outcome?
Thanks


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