# 30yo female code on a BLS transport w/ possible seizure activity.



## SoCal911 (Apr 11, 2012)

Hey guys, I chose to put this in the ALS section hoping I could get a little more insight from the guys who've completed their medic training. Yesterday I had a 29yo patient on a routine transport to receive a head scan following what they felt was a syncopal episode at home, test came back normal so the doc wanted a head scan to rule anything else out. 

Back story, previous Hx of depression only. NKDA on no Meds and no Meds were given. 

So following the scan were enroute back to the sending facility (the scan used no contrast invade you were wondering) when my patient who was talking to me and I had just completed vs on (p88 r12-14 bp130/82) stopped talking and twitched/jolted ONE time (looked very similar to a defib shock) she went completely limp, eyes rolled back, little to no pupil response, non-responsive to verbal or painful, pulse less and apneic... At this point I've alerted my partner and he's pulled to the shoulder and hopped in back. Now, having a very hard time believing my 29yo pt just dropped in full arrest, I grabbed my ears and checked for heart sounds - nothing. So grabbed the defib from outside the unit and started to slap the pads on, while my partner verified no pulse and proceeded to give (2) very sharp compressions.

Here's the interesting part... Just after the second compression the patient jolts and begins to breath and slowly becomes alert (not oriented in the least) - vs were taken immediately and were nearly identical to the vs taken 5 minutes prior, slowly she becomes further oriented but only to person and place (the back of an ambulance) and she still has no idea what's up.

I'm suspecting that those compressions had something similar to a precordial thump effect, being her down time was about a minute if that. 

What the hell happened? Any ideas?


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## Veneficus (Apr 11, 2012)

There is no way to tell if the change was spontaneous or the result of therapy.(compressions)


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## usalsfyre (Apr 11, 2012)

Or whether the patient simply experienced a syncopal episode.


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## Farmer2DO (Apr 11, 2012)

SoCal911 said:


> she went completely limp, eyes rolled back, little to no pupil response, non-responsive to verbal or painful, pulse less and apneic...
> 
> I grabbed my ears and checked for heart sounds - nothing.
> 
> while my partner verified no pulse





usalsfyre said:


> Or whether the patient simply experienced a syncopal episode.



It sounds like a did a decent assessment.  Why would you say that?


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## usalsfyre (Apr 11, 2012)

I've just seen a couple of cases of panicked BLS providers starting compressions inappropriately lately.


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## Aidey (Apr 11, 2012)

Ok, stupid question. Why was the patient being transported in an ambulance? Was there no scanner available at the sending facility?


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## FLdoc2011 (Apr 11, 2012)

Young adult with syncope and now what looks like aborted cardiac arrest.... certainly arrhythmia/cardiac until proven otherwise in my mind.    What'd EKG look like?


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## DrankTheKoolaid (Apr 11, 2012)

Sounds oddly similiar to an 18 year old full arrest i had that had a witnessed seizure on a bicycle while riding.   Turns out to have been his 3rd "seizure".    

In reality it turns out the kid had an undiagnosed Prolonged QT syndrome causing lethal changes and the physicians suspect that the falls from the past 2 cardiac episodes were essentially precordial thumps enough to bring him out of the lethal rhythms.

This may be what you had seen also.  Would be a great call for you to do some follow up on


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## SoCal911 (Apr 11, 2012)

Aidey said:


> Ok, stupid question. Why was the patient being transported in an ambulance? Was there no scanner available at the sending facility?



No scanner available at the sending facility, she was admitted for a witnessed episode of what the family described as a syncopal. No history of previous syncopal. I did a very thorough assessment to verify, no pulse (at either radial or carotid - just to be sure I didn't miss one) no reps, none to extremely sluggish pupil response, and no heart sounds when checked (I had a hard time believing a 29 yo just coded, so I threw on my ears and it was silent) this was verified by my partner (I wanted to be 100% sure I wasn't seeing things). Now for some clarification, my partner has 3 years experience in a heavy heavy 911 system and I myself have about 7 months in different 911 systems and where we work weve both run full arrests as a bls unit PTA of an ALS squad. I've seen arrests and the whole bit - I can assure you that this was not a case of BLS provider panic or a syncopal. This was as sure as my mother lives today - a full arrest.


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## NYMedic828 (Apr 11, 2012)

SoCal911 said:


> No scanner available at the sending facility, she was admitted for a witnessed episode of what the family described as a syncopal. No history of previous syncopal. I did a very thorough assessment to verify, no pulse (at either radial or carotid - just to be sure I didn't miss one) no reps, none to extremely sluggish pupil response, and no heart sounds when checked (I had a hard time believing a 29 yo just coded, so I threw on my ears and it was silent) this was verified by my partner (I wanted to be 100% sure I wasn't seeing things). Now for some clarification, my partner has 3 years experience in a heavy heavy 911 system and I myself have about 7 months in different 911 systems and where we work weve both run full arrests as a bls unit PTA of an ALS squad. I've seen arrests and the whole bit - I can assure you that this was not a case of BLS provider panic or a syncopal. This was as sure as my mother lives today - a full arrest.



Just a hunch but if shes being scanned for "what the family described as a syncopal episode" then id imagine theres a good chance that its the same thing as you witnessed.

Who is to say she doesn't have an extremely irritable heart regardless of age (some people are that unlucky) and is not getting a few minutes worth of pulseless v-tach or something similar that corrects itself. Technically it is a cardiac arrest but at the same time to an uniformed family who just thinks she fainted, its a syncope.

Had you gotten the AED on before it corrected itself we would have had an entirely different viewpoint. (not implying you were slow or anything)


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## firecoins (Apr 11, 2012)

Several questions

How was this disposed of? Did you call ALS? Divert to the closest ER? 

Why is the AED kept putside the unit?


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## m0nster986 (Apr 11, 2012)

What was the patient's medical history besides, "syncope"?


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## SoCal911 (Apr 11, 2012)

Now Fire took off before I could get a look at the 12-lead but I did hear that they did endup bypassing several hospitals to get her to a speciality center - not by pt request. Fire also called and gave us an adahboy


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## SoCal911 (Apr 11, 2012)

m0nster986 said:


> What was the patient's medical history besides, "syncope"?



Hx of anxiety - that's all. She had one possible syncopal and that's why she was admitted, no Hx of it. On no Meds and NKDA.


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## SoCal911 (Apr 11, 2012)

firecoins said:


> Several questions
> 
> How was this disposed of? Did you call ALS? Divert to the closest ER?
> 
> Why is the AED kept putside the unit?



ALS was activated and the pt was transported by als. And.. we kept the first in bag and AED in the compartment outside, we're first on scene quite often, its more accessible to grab and go on a call, additionally we'd have to pull over to use the AED in the back of the unit anyways, so we felt the benefits of having it in that compartment outweighed the negatives.

I've walked in on plenty of arrests, but never had one in the rig.


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## SoCal911 (Apr 11, 2012)

NYMedic828 said:


> Just a hunch but if shes being scanned for "what the family described as a syncopal episode" then id imagine theres a good chance that its the same thing as you witnessed.
> 
> Who is to say she doesn't have an extremely irritable heart regardless of age (some people are that unlucky) and is not getting a few minutes worth of pulseless v-tach or something similar that corrects itself. Technically it is a cardiac arrest but at the same time to an uniformed family who just thinks she fainted, its a syncope.
> 
> Had you gotten the AED on before it corrected itself we would have had an entirely different viewpoint. (not implying you were slow or anything)



Agreed, the way it happened didn't allow for that unfortunately.


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## Veneficus (Apr 12, 2012)

FLdoc2011 said:


> Young adult with syncope and now what looks like aborted cardiac arrest.... certainly arrhythmia/cardiac until proven otherwise in my mind.    What'd EKG look like?



Strangely enough I saw two people in the last few weeks sent to neuro from cardio admitted for syncope, both had negative scans, and both ended up with cardiac etiology dx after negative scanning.


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## CCNRMedic1982 (Apr 12, 2012)

One, awesome original post and sounds like a really good assessment. I don't remember reading why this was a BLS transport and not an ALS? I'm not sure how the transports go where you are from. But would've thought that to be an ALS transport before the arrest.


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## CCNRMedic1982 (Apr 12, 2012)

Also, what test were preformed at the referring facility?


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## SoCal911 (Apr 12, 2012)

CCNRMedic1982 said:


> One, awesome original post and sounds like a really good assessment. I don't remember reading why this was a BLS transport and not an ALS? I'm not sure how the transports go where you are from. But would've thought that to be an ALS transport before the arrest.



Well thanks  She was deemed stable enough for BLS by the referring MD. Honestly I'm not sure what test were performed. All I got was "blood work and labs were normal" from the RN prior to transport.


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## Veneficus (Apr 12, 2012)

Veneficus said:


> Strangely enough I saw two people in the last few weeks sent to neuro from cardio admitted for syncope, both had negative scans, and both ended up with cardiac etiology dx after negative scanning.



Consulted neuro on this today.

Apparently the purpose of a scan for syncope in young adults is to rule out a neoplastic disease or a vascular anomaly. (malformation, arteritis, etc)

As I understand, the scan is performed even if a cardiac dx is suspected prior to the CT and the neurologist I spoke with said he had never seen a case where a young person presented with syncope instead of seizure in a neoplastic disease nor a syncope without total loss of consciousness in a ruptured AV malformation (aka bleed) in his career. (at a large academic facility)

I am guessing it was a BLS transfer because nothing prior to transport indicated an impending problem and likely a nondiagnostic CT was expected.
(Or maybe a diagnostic was hoped for so cards wouldn't get the patient back in the spirit of punting on first down  )


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## FLdoc2011 (Apr 12, 2012)

I've seen a bunch of bleeds from aneurysm/AVMs that didn't present with LOC.  granted they all pretty much had severe HA and/or some sort of neuro defect and certainly doesn't seem very likely high on the differential in the case.


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## johnrsemt (Apr 15, 2012)

I had a patient brought into our ED that her complaint was multiple syncopal episodes that day:   she was talking 30-40 before her daughter witnessed one (daughter is OR nurse): (Pt lived in an assisted living center, and would remember walking down the hall and wake up on the floor a few seconds later)  she said that when she started to feel it happening she would look at watch and they were lasting 5-15 seconds.
   The medic crew that brought her in told us that after an evaluation they brought her in BLS because there "is no way possible what the patient was describing was happening".

   During my workup:  blood, 12 lead, monitor, O2; patient stated that it was going to happen again; and flat lined on me.   after what daughter described was "1 second of 'OH S**T"' I checked for a carotoid pulse and hit code button on the wall.  I dropped the head of bed, and side rail and dropped the bed and got my hands on her chest.  That episode lasted about 8 seconds
   The patient opened her eyes looked at me and asked if I saw it happen.   The ED staff (everyone) came in and looked at me like I was an idiot;  (New medic doesn't know what he is doing).  ED doctor told charge nurse to take me off patient care;  and she coded again.   Charge nurse and ED doctor had deer in headlights look as they were both checking for pulse while they just stood there.   I asked them if they wanted me to start CPR and got blank stares.
    As I pushed the nurse out of the way and got bed ready for CPR she WOKE up again.     Doctor mentioned to the nurse that maybe I did know what I was doing,  since neither of them could find a pulse either.

   Turns out that the patient's heart was actually stopping every few minutes to take a break.  She ended up with an on demand pacemaker early the next morning.   (She coded 22 times before we could transfer her)   The ALS crew that brought her to us was surprised when we showed them later what she was doing.


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## Veneficus (Apr 15, 2012)

FLdoc2011 said:


> I've seen a bunch of bleeds from aneurysm/AVMs that didn't present with LOC.  granted they all pretty much had severe HA and/or some sort of neuro defect and certainly doesn't seem very likely high on the differential in the case.



Sorry, I wasn't trying to say that aneurysm/AVMs always present with LOC, I asked specifically about presenting with syncope, not other symptoms.


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## FLdoc2011 (Apr 15, 2012)

johnrsemt said:


> I had a patient brought into our ED that her complaint was multiple syncopal episodes that day:   she was talking 30-40 before her daughter witnessed one (daughter is OR nurse): (Pt lived in an assisted living center, and would remember walking down the hall and wake up on the floor a few seconds later)  she said that when she started to feel it happening she would look at watch and they were lasting 5-15 seconds.
> The medic crew that brought her in told us that after an evaluation they brought her in BLS because there "is no way possible what the patient was describing was happening".
> 
> During my workup:  blood, 12 lead, monitor, O2; patient stated that it was going to happen again; and flat lined on me.   after what daughter described was "1 second of 'OH S**T"' I checked for a carotoid pulse and hit code button on the wall.  I dropped the head of bed, and side rail and dropped the bed and got my hands on her chest.  That episode lasted about 8 seconds
> ...



They couldn't put in a transvenous pacer in the ED?


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## mycrofft (Apr 15, 2012)

johnrsemt said:


> I had a patient brought into our ED that her complaint was multiple syncopal episodes that day:   she was talking 30-40 before her daughter witnessed one (daughter is OR nurse): (Pt lived in an assisted living center, and would remember walking down the hall and wake up on the floor a few seconds later)  she said that when she started to feel it happening she would look at watch and they were lasting 5-15 seconds.
> The medic crew that brought her in told us that after an evaluation they brought her in BLS because there "is no way possible what the patient was describing was happening".
> 
> During my workup:  blood, 12 lead, monitor, O2; patient stated that it was going to happen again; and flat lined on me.   after what daughter described was "1 second of 'OH S**T"' I checked for a carotoid pulse and hit code button on the wall.  I dropped the head of bed, and side rail and dropped the bed and got my hands on her chest.  That episode lasted about 8 seconds
> ...



Yeah we had a guy like that in Lincoln NE. Unnerving to say the least but he had a good sense of humor. This was before implantable defibs.

For the folks fixating upon CNS affect, know that the brain goes byebye surpisingly fast when the heart stops in most people. You'd think a few seconds "on reserve" or something, but, no. Lights out.

Sounds like a good call OP! Pt owes you a brownie.


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## Remeber343 (Apr 16, 2012)

Sounds like it could possibly be Adams–Stokes Syndrome, but usually people are still able to breath through that.  Could be a lot of things though haha.  If you are able to do follows ups, try contacting the hospital they transported to or maybe the als agency that did the transport.


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## crazycajun (Apr 20, 2012)

Remeber343 said:


> Sounds like it could possibly be Adams–Stokes Syndrome, but usually people are still able to breath through that.  Could be a lot of things though haha.  If you are able to do follows ups, try contacting the hospital they transported to or maybe the als agency that did the transport.



Not necessarily. Adams-Stokes can present with complete transient Asystole in some PT's and cause complete arrest leading up to complete heart block. Many AS PT's experience a quick seizure like activity and go full code within seconds only to return to normal minutes later without intervention. Some never realize it even happened.


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## Remeber343 (Apr 20, 2012)

Which sounds like what happened in this case...?  I mean it could be many things, but what he described sounds like it could be a possibility.


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## crazycajun (Apr 21, 2012)

Remeber343 said:


> Which sounds like what happened in this case...?  I mean it could be many things, but what he described sounds like it could be a possibility.



I agree. i would have loved to see the 12 lead during the episode or even after to see if there is any sort of block going on or arrhythmia's.


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## OzAmbo (May 7, 2012)

crazycajun said:


> I agree. i would have loved to see the 12 lead during the episode or even after to see if there is any sort of block going on or arrhythmia's.



Even a 3 lead would suffice in this case

The obvious choice here is a transient tachyarrhythmia that self reverted. I would expect them to know if she has WPW syndrome but paroxsysmal VT or SVT would account for her hx of syncope. Possibly even the occasional ectopic and an R on T but i think she would have to be unlucky for this to happen more than a couple of times. 

It accounts for most of her symptoms, but you would expect a period of poor perfusion +/- some ACS symptoms, canon-a-waves (if your lucky enough to see them - and they are cool).

Adams stokes sounds like the culprit


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## hawkinstyler (May 28, 2012)

I'm confused.. although undoubtedly a syncopal episode would cause a patient's BP to tank, how would that amount to apnea and sudden cardiac arrest? Surely there was some underlying condition such as an electrolyte imbalance, or something entirely unrelated which caused the episode. Never heard of anything like this before.


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## TatuICU (May 28, 2012)

hawkinstyler said:


> I'm confused.. although undoubtedly a syncopal episode would cause a patient's BP to tank, how would that amount to apnea and sudden cardiac arrest? Surely there was some underlying condition such as an electrolyte imbalance, or something entirely unrelated which caused the episode. Never heard of anything like this before.



Look up stokes Adams


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## Handsome Robb (May 29, 2012)

Here's a good one. 

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1518479/


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## mycrofft (May 29, 2012)

*Picking nits*

Low BP causes syncope.

Syncope and low BP may both occur due to cardiac difficulties or some intracranial stuff, or poisoning (even if it is Rx).

Syncope does not cause anything except LOC and an involuntary getting off of one's feet.


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## hawkinstyler (May 29, 2012)

Stokes-Adams huh.. when I see this I'm compelled to think of Cheyne-Stokes respirations, ha! Anyway that's clearly irrelevant, I've never heard of Stokes-Adams, just something we never covered in class. Very interesting to see how the description correlates almost exactly to what was described in the original post. Never doubted anyone's assumptions, I was just a little clueless because this seemed such a rare occurrence to me. Thanks, yet another thing I can add to the memory bank.


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