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

[Veneficus]

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 )

 

[FLdoc2011]

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.

 

[johnrsemt]

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.

 

[Veneficus]

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.

 

[FLdoc2011]

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.

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

 

[mycrofft]

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.

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.

 

[Remeber343]

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.

 

[crazycajun]

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.

 

[Remeber343]

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.

 

[crazycajun]

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.

 

[OzAmbo]

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

 

[hawkinstyler]

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.

 

[TatuICU]

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

 

[Handsome Robb]

Here's a good one.

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

 

[mycrofft]

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.

 

[hawkinstyler]

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.