70Y/O Male Dizzy/Lightheaded/Syncope

JJC211

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You are called for a 70 Y/O male, woke up feeling very dizzy/lightheaded. Walked himself to a kitchen chair and sat there for a couple hours. Family found patient sitting in chair and called 911 for him. When you arrive, you see the patient sitting upright, head slightly forward. Heavyset Caucasian male (Approx 350Lbs) Skin: Cool, pale, diaphoretic. Alert, very lethargic and answers questions very quietly. Tells you he feels extremely dizzy and has a hard time staying awake. Pulse is strong, regular, and slow. Vitals: BP 125/70 (auto), Pulse 35 (Pulse ox), RR 15, 93% on room air. Family states patient has a recent history of a heart attack and had a stent placed they think. Patient confirms with a nod.

You package the patient and move him to your ambulance. IV access successful (20ga LAC), 12 lead was obtained while getting IV. ECG shows bradycardia, very small QRS complexes and no discernible P waves. No elevation noted. New set of vitals: BP 142/92 (auto), Pulse 22 (Monitor), RR 14, 94% on 2LPM CapnoCannula, Etco2 48.

What is your course of treatment, and would you consider this patient stable or unstable?
 

StCEMT

Forum Deputy Chief
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Adjust the settings so I can see the QRS complexes. Not about to walk in a potential MI without having done some basic effort to rule it out/troubleshoot. Very well could be a CHB caused by an MI, so I'd like to know as that would dictate my treatment plans a bit.
 

Peak

ED/Prehospital Registered Nurse
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Further assessment is warranted. Does the patient have normal lung sounds and heart tones? What is his NIHSS? Does the dizziness worsen with movement suggestive of cerebellar stroke? Any other focal neurologcial deficits? What is his normal BP? Does he take any medications, and is it possible he took an incorrect amount of his medications? Does he have a history of hypothyrodism? History of adrenal insufficiency or any reasons to suspect adrenal fatigue? Any other medical history? Does he have a negative right sided and posterior EKG? BGL? Otherwise normal physical exam of the head/neck/chest/abdomen?

Less applicable to most field services but this patient needs a POC cardiac ultrasound (and I would look at his lungs while I'm at it), and a Chem 8 and Trop if available.

Consider chronotrops/anticholinergics, calcium if he is on calcium channel blockers, levothyroxine if a history of hypothyroidism, steroids if suspected adrenal insufficiency. Strongly consider TC pacing (especially since the patient can currently support anxiolysis or pain control if needed). Place two large bore IVs. Titrate O2 with a goal saturation of 98% (higher flows are okay if the patient is in extremis but MI/Stroke cannot be ruled out). Priority transport to a cardiac center than can place a TV pacer and stent, ideally this would also be at least a primary stroke center. I would consider ASA or clopidogrel.

DDx: Stroke vs MI vs drug mediated bradycardia vs profound electrolyte abnormality vs progression of pathology from prior MI vs other cardiac pathology vs intrathoracic pathology vs intracranial pathology vs endocrine disease.

Symptomatic profound bradycardia is unstable.
 

Gurby

Forum Asst. Chief
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I'd check a manual BP... 120/80 -> 140/90? Iiiiiiii don't believe it. Automatic cuffs I've used often have a hard time when the HR gets really low, and if the cuff is mis-sized you can get a false reading too.

It would be interesting to know how recent that MI+stent was.
 

Akulahawk

EMT-P/ED RN
Community Leader
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While there are more things we'd do in the hospital with him, this is what I would consider, knowing the limitations we have in the prehospital arena.

While I would certainly consider this a symptomatic brady and unstable at that, what's missing from this scenario is what meds this guy's on. As far as Tx goes, I'm going to get a couple of IV's with at least an 18g if possible. Why? I want med and fluid access. I'm going to want to get a manual BP measurement because of the NIBP limitations when HR is low. I might try a trial of atropine, but I will get the pads in place and give great consideration to pacing. If I know what meds he's on, when his last surgery was and symptoms at that time, that may change my plan. I'm currently thinking CHB in the setting of another MI that isn't seen by the 12-lead. If I think he can handle sedation, I'll do that before I start pacing him. Oh, and based on his past and what seems to be going on, I'm going to bypass some hospitals and head for a facility that has a cath lab. While my own hospital is designated as a chest pain center and is a primary stroke center, I wouldn't take him there as they do not have what this guy needs. An extra 10 minutes on the road will save him about 2-3 hours while waiting for CCT transport to take him to a facility that has what he's going to need.
 

medichopeful

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Get the HR up before he arrests.
This. I wouldn’t wait until I got to the ambulance to start aggressive treatment at the point of contact.
 
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