# 80 yoBF w/ syncopal episode



## Epi-do (Aug 9, 2009)

Here's a recent run that we had.  Just curious if anyone had any comments for me.
*
Dispatch:* difficulty breathing, upgraded to cardiac arrest
While enroute, dispatch advises that a woman called, stated her mom was having problems breathing, suddenly screams that she has stopped breathing all together, and then hangs up the phone.  The dispatcher tries to call back, but no one answers the phone.​*
Scene:*  We arrive to find a new, well-kept home with a couple people in the front yard.  The patient is sitting in a chair at the kitchen table.  Her daughter in on the phone and a neighbor is next to her.

*Pt's story:*  She states she had been in the kitchen fixing something to eat and began feeling dizzy.  She walked over to the table and had a seat, and the next thing she knows, she is on the floor.  She has no idea how she got there.  She has had similar episodes where she has felt dizzy, but it always passes if she sits down and she has never "passed out" before.  She also gets easily winded when going up/down the stairs, but is able to walk around the house or yard without any difficulty.  She denies any increase in the incidence of these episodes of dizziness or getting winded.

*Daughter's story:*  My mom was in the kitchen when she got this "look" on her face and sat down at the kitchen table.  She has spells where she gets dizzy, so I just assumed that is what was going on.  She had her face in her hands and was breathing funny.  I went to finish fixing her food for her and noticed that she was sort of slumped over.  She didn't look like she was breathing, so I called 911 and also called my neighbor to come help.  I called her name and she didn't respond to me.  She had a stress test done sometime during the first part of July and it was ok.  The doctor told us that whatever she is doing, she needs to keep doing it because she looks great for being 80.  I have noticed that she has been having these dizzy moments a bit more frequently than in the past.

*Neighbor's story:*  I came over when I heard <daughter> calling for help.  I came into the house and <patient> was in the chair, not responding to anyone and it didn't look like she was breathing.  I pulled her out of the chair and laid her on the floor to start CPR when she suddenly started breathing again.  She came too and I helped her back into the chair.

*Initial impression:*  The pt is an elderly black female, sitting in a chair.  She is pale, cool, and diaphoretic and her respiratory effort is slightly labored.  She is A&Ox3.

*PE:* BBS=slight wheezes at bases of both lungs; PERL; + PMSx4 extremeties; radial pulse is undetectable; HR=60 (obtained by listening to heart w/ steth.); no obvious signs of any sort of trauma noted

The patient denies difficulty breathing/SOB, CP, dizziness, N/V, or any pain.  She states she has not fallen, had any other type of trauma, or any recent medical procedures.
*
PMHx/RX/Alg.:*  2 different statins for hyperlipidemia.  Atenolol and Diovann for htn.  Also takes potassium.  The patient states she is confident she did not take to much of any of her meds, either accidentally or intentionally.  She has had no recent changes in dosage, and has been on all meds for quite some time.  She denies any other history or meds.

She has NKA.

*Vital signs:*  blood sugar 157 mg/dL; initial BP 92/58; RR 14-16
VS enroute to ER as follows:​






*Tx:*  albuterol 2.5 mg via neb w/ O2 @ 8 lpm; IV established (18 g LAC) w/ 250 ml NaCl given throughout transport; cardiac monitor & 12 lead performed

The initial strip and 12 lead were as follows:






*Changes during transport to ER:*  Albuterol alleviated the wheezes, and the patient was switched from a neb (once completed) to N/C @ 4 lpm; skin now pink, cool, clammy

If there is anything else you want to know, just ask.  I will do my best to remember any additional details.  

I'm just looking for general comments.  I realize protocols vary from area to area, but am curious if anyone would do anything differently.  I would love to know why she became syncopal, but don't know if I will be able to get back to that particular ER to follow up.  I know there are countless things that could have caused it, especially given her age.  I am wondering if something may have caused her to brady way down, until she wasn't perfusing adequately, leading to the syncope.  What does everyone else think?


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## Onceamedic (Aug 9, 2009)

looks to me like symptomatic bradycardia.  I would try a little atropine to see if I can't kick that rate up.


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## Ridryder911 (Aug 9, 2009)

Who knows why the brady? Vagalytic, Sick sinus..electrolyte imbalance? I definitely would NOT give atropine as it has not affected the blood pressure and personally would not like to see a run of SVT or VT. I personally don't want to place undue pressure on an already diseased heart. 

Give some fluid bolus, watch and monitor her breathing and lung sounds, be prepared to pace if need be. Personally believe that she will have a permanent one within 24 hours.


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## MrBrown (Aug 9, 2009)

I agree symptomatic brady; her BP seems to be picking up but it's still kinda low, although how did her perfusion and mental status/GCS change after treatment?

I'd start a line, get some fluids onboard and try .6 of atropine 3-5min up to 1.8 if that didn't work and the patient stayed ALOC/poor perfusion I'd pace or hang an adrenaline infusion


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## Epi-do (Aug 9, 2009)

I had thought about atropine, but even though she had been syncopal before I got to her, she was "stable" once I got to her - A&Ox3, had no complaints, was no longer dizzy, etc.  The only thing I "had" was her skin condition.  SBP has to be below 90, the patient has to be altered or dizzy in order for me to give atropine.  I could have called and asked a doc, but the particular ER we were going to would have told me no since we weren't really that far out.


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## MrBrown (Aug 9, 2009)

Ridryder911 said:


> Who knows why the brady? Vagalytic, Sick sinus..electrolyte imbalance? I definitely would NOT give atropine as it has not affected the blood pressure and personally would not like to see a run of SVT or VT. I personally don't want to place undue pressure on an already diseased heart.
> 
> Give some fluid bolus, watch and monitor her breathing and lung sounds, be prepared to pace if need be. Personally believe that she will have a permanent one within 24 hours.



You thinking perhaps LVH (would fit with her HTN) and atropine might cause something funky?


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## emtjack02 (Aug 9, 2009)

She doesn't appear to be HoTN by her MAP, except for the first reading and the initial no radial.  Seems the fluid was good enough..for now.


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## falcon-18 (Aug 9, 2009)

It is sinus brady, with SOB.

but, was she somker? was she very tired?( sleep a short time ) . 

after fluids given how was the BP ? radial pulse palpating or no ? 

this ECG after  fluids given ? 




when you will give him fluids . did you check her chest no fluids?



thank you


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## Aidey (Aug 10, 2009)

Her QT/QTc is just a smidge on the long side. 

Does she monitor her BP at home? Has she lost weight recently (say in the last few months or so). Maybe she is over medicated causing her BP to drop.


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## maxwell (Aug 10, 2009)

ecg: sinus bradycardia with markedly good R wave progression (so it's most likely not a pump problem).  look at the htn meds.  can her meds do this?  (yes.  i hear that drugs that treat hypertension ACTUALLY lower your blood pressure!)  can she be just old?  (yes.)   

my plan: 500mL fluid bolus, no atropine, find out what dose of her meds she really took that day


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## Epi-do (Aug 10, 2009)

falcon-18 said:


> It is sinus brady, with SOB.
> 
> but, was she somker? was she very tired?( sleep a short time ) .
> 
> ...



Even though she had faint wheezes that I took care of with albuterol, she never once complained that she felt short of breath.  I asked her at different times while evaluating and re-evaluating and she denied it every time.  She is not a smoker, and outside of getting winded when walking the stairs (which she had not been doing) she denied fatigue.  If you look at the vital signs, you can see that her BP gradually increased throughout the transport.  By the time we got to the ER her radial pulse was palpable.  The ECG was done enroute to the ER and fluids were being given simultaneously.  After the neb was complete, BBS=clear for the rest of the transport.




Aidey said:


> Does she monitor her BP at home? Has she lost weight recently (say in the last few months or so). Maybe she is over medicated causing her BP to drop.



She does not monitor her BP at home, and denied any recent weight loss.  I did ask her about overmedication, and she was adamant that she took all her meds exactly as prescribed.


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## boingo (Aug 10, 2009)

She's beta blocked w/hr in the 50's, nothing I'd get too excited about.  I'd keep her on the monitor, saline lock and transport.


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## JeffDHMC (Aug 11, 2009)

Word........


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## Aidey (Aug 11, 2009)

I was thinking overmedicated as in her medication dose is too high for her. If she had lost weight or had diet changes or something it could have made it so that her BB dose needed to be lowered. 

Sure a HR in the 50s in a pt on BBs is pretty normal, however, multiple syncopal episodes over a period of time that are increasing in frequency are not.


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## Epi-do (Aug 11, 2009)

Aidey said:


> I was thinking overmedicated as in her medication dose is too high for her. If she had lost weight or had diet changes or something it could have made it so that her BB dose needed to be lowered.
> 
> Sure a HR in the 50s in a pt on BBs is pretty normal, however, multiple syncopal episodes over a period of time that are increasing in frequency are not.








  I can be a bit slow sometimes.  That makes sense to me now, but didn't at the time I first read it.


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## Aidey (Aug 11, 2009)

lol, it's ok. We all have our moments.


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