# Syncope



## isabellamarie (Feb 14, 2021)

What would you guys personally do in this situation

14 Y/O Female
Passed out during a workout
Very slow to answer questions
Seems disoriented 
Has passed out before but states that this time feels different.


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## ffemt8978 (Feb 14, 2021)

ABC's, vitals x3, SAMPLE, contact guardian


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## NomadicMedic (Feb 14, 2021)

An assessment, to start.


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## Jim37F (Feb 14, 2021)

If off duty at the gym as well, call for an ambulance.

If on duty and responding? Get a full set of vitals, determine are they actually alert and orientated, get a full medical history, medication list, allergies, OPQRST, etc, to determine appropriate hospital, hand off to EMS for transport. Oh yeah, 14 year old, get in contact with parent/guardian.

Unless there's something particularly out of left field, this patient will probably get a nice smooth, non-emergent ride to the closest ER with BLS monitoring.


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## MMiz (Feb 14, 2021)

Off duty: Activate emergency response (911).  Have friends/family with patient call the parent/guardian.

On duty:  Jim37F covered it.

I see this a lot in my non-EMS job, both with adults and pediatrics.  Our policy is to contact 911 for loss of consciousnesses and wait for EMS.

Being slow to answer questions, disorientation, and someone stating that this "feels different" seem to be pretty typical.


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## Peak (Feb 15, 2021)

Do you have a of a bit better description of the syncopal event? Did the patient suddenly lose consciousness, did she lose consciousness shortly after racking a bar after heavy squats, slowly become more and more lightheaded throughout her workout, and so on? Did she have any preceding dizziness, tachycardia/palpitations, chest pain, et cetera? Does she take any supplements or is on any specific diet? Does she present risk factors for hypercoaguable state (birth control, chance of pregnancy, smoking, hormonal supplements, long periods of inactivity)? How much fluid has she taken in during the workout, how much today? Does the patient appear clinically hydrated and/or well perfused. How many times has she urinated today, when was her last urination, what color was it? Does the patient present any focal neurological deficits or only a series of vague symptoms? Diet concerning for anemia? Other general history and physical exam?

EMS: 12 lead. BGL. NIHSS, cerebellar assessment. Serial vitals. Access. Replacement fluids if indicated. Transport depending on clinical assessment.

ED add: CBC, CMP, trop, preg, dimer. Consider CXR or CT. Consider tox. Disposition depending on clinical course.


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## E tank (Feb 16, 2021)

Peak said:


> ED add: CBC, CMP, trop, preg, dimer. Consider CXR or CT. Consider tox. Disposition depending on clinical course.




Or some apple juice, see how she feels and go from there....


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## Peak (Feb 16, 2021)

E tank said:


> Or some apple juice, see how she feels and go from there....



yeah... try to justify that MDM in court


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## DrParasite (Feb 16, 2021)

Peak said:


> yeah... try to justify that MDM in court


MDM?


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## E tank (Feb 16, 2021)

Peak said:


> yeah... try to justify that MDM in court


had to look that up...but it goes to my point. No clinical insight, no clinical assessment, and no real "MDM"...medical decision making? What medical decision making is there in ordering every test and the kitchen sink for a kid like this? When the only difference in the "MDM" in an adolescent female "syncope" on exertion and say an 80 year old with afib and hypertension being a pregnancy test, you got a real "MDM" issue....


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## Peak (Feb 16, 2021)

E tank said:


> had to look that up...but it goes to my point. No clinical insight, no clinical assessment, and no real "MDM"...medical decision making? What medical decision making is there in ordering every test and the kitchen sink for a kid like this? When the only difference in the "MDM" in an adolescent female "syncope" on exertion and say an 80 year old with afib and hypertension being a pregnancy test, you got a real "MDM" issue....


What are your differential diagnosis?


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## PotatoMedic (Feb 17, 2021)

Peak said:


> What are your differential diagnosis?


Lupus.


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## Comfort Care (Mar 4, 2021)

E tank said:


> had to look that up...but it goes to my point. No clinical insight, no clinical assessment, and no real "MDM"...medical decision making? What medical decision making is there in ordering every test and the kitchen sink for a kid like this? When the only difference in the "MDM" in an adolescent female "syncope" on exertion and say an 80 year old with afib and hypertension being a pregnancy test, you got a real "MDM" issue....


Kitchen Sink? these are basic labs we run for near syncope/ syncopal episodes. 🤣. r/o ectopic, PE, Cardiac, etc. many differential dx.


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## E tank (Mar 4, 2021)

el EMT said:


> Kitchen Sink? these are basic labs we run for near syncope/ syncopal episodes. 🤣. r/o ectopic, PE, Cardiac, etc. many differential dx.


Who is 'we' exactly? And an 80 year old that passes out gets the exact same diagnostic work up as a hormonal adolescent?🤣.

 Sure, I guess if medical training and insight are lacking you check every single box and send a $4500 bill to a dehydrated teenager's parents. And people scratch their heads trying to figure out why the health care system is on the verge of collapse....


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## Peak (Mar 4, 2021)

Previously healthy teens can certainly with life threatening disease. I’ve had many teens with strokes, PE, myocarditis, structural heart disease, and kidney disease who initially presented with either loss of consciousness or altered mental status during activity and no other prior history.

Sure most teens will likely have a benign pathology to their complaint, but so will most adults. Simply assuming a patient will be healthy or is dramatic is negligent.


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## Comfort Care (Mar 4, 2021)

Peak said:


> Do you have a of a bit better description of the syncopal event? Did the patient suddenly lose consciousness, did she lose consciousness shortly after racking a bar after heavy squats, slowly become more and more lightheaded throughout her workout, and so on? Did she have any preceding dizziness, tachycardia/palpitations, chest pain, et cetera? Does she take any supplements or is on any specific diet? Does she present risk factors for hypercoaguable state (birth control, chance of pregnancy, smoking, hormonal supplements, long periods of inactivity)? How much fluid has she taken in during the workout, how much today? Does the patient appear clinically hydrated and/or well perfused. How many times has she urinated today, when was her last urination, what color was it? Does the patient present any focal neurological deficits or only a series of vague symptoms? Diet concerning for anemia? Other general history and physical exam?
> 
> EMS: 12 lead. BGL. NIHSS, cerebellar assessment. Serial vitals. Access. Replacement fluids if indicated. Transport depending on clinical assessment.
> 
> ED add: CBC, CMP, trop, preg, dimer. Consider CXR or CT. Consider tox. Disposition depending on clinical course.


Peak nailed it!!
Not saying we're gonna order the kitchen sink, however, we cant just focus on the apple juice. A little critical thinking goes a long way.


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## E tank (Mar 4, 2021)

Peak said:


> Simply assuming a patient will be healthy or is dramatic is negligent.


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## silver (Mar 4, 2021)

A history and physical would drastically narrow your differential and using a Bayesian approach to clinical decision making make ordering many of those tests not necessary.

And by physical I mean like regular run of the mill physical, not get out my stroke cards physical.


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## NomadicMedic (Mar 4, 2021)

Why are you arguing about testing in the ED? This (from the original post) seems to be a simple BLS scenario. This is a prehospital forum still, right?

Assess the patient. 
Check a CBG. 
Get a full set of vitals. 
Stroke scale. 
Transport. 

There was not enough information given in the OP to go any further than that.


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## E tank (Mar 5, 2021)

NomadicMedic said:


> Why are you arguing about testing in the ED? This (from the original post) seems to be a simple BLS scenario. This is a prehospital forum still, right?
> 
> Assess the patient.
> Check a CBG.
> ...


Yeah...caught in the vortex...but this is instructive to anyone not to over think stuff...BLS or  not....


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## medichopeful (Mar 5, 2021)

Basic vitals, BGL, basic assessment/interview, and 12-lead.  Contact their guardian, advise that they should probably get checked out by either their PCP or the ER.  I'd be more than happy to wait for the parent to come pick them up to bring them there so they don't get stuck with a huge bill.

It's probably something unremarkable, but young patients can have significant events as well.


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## Chris EMT J (Apr 28, 2022)

isabellamarie said:


> What would you guys personally do in this situation
> 
> 14 Y/O Female
> Passed out during a workout
> ...


Access scene for clues like pill bottles, bottles of alcohol, etc. 

ABCs, A&O, vitals, ECG, ask guardian if present a SAMPLE,  and work on stabilizing then just direct to the ED and the investigations can start.


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