passing out from overexertion?

[Smash]

The pt. was tested for HOCM, but they did not know the results of the test as it had just been a couple days ago that she'd been tested. The drs were suspecting that she might have HOCM because her brother has it. At this point she was not seeing a cardiologist and did not have a family dr.

Funny, that was exactly what I was thinking. HOCM is high on the list of badness for exercise induced syncope in the young, and there is obviously some faulty genes floating around the family. I'd love to know the rhythm she was in, and what the murmur was.

 

[18G]

I had a very similar episode happen to me during some exercise which was only moderate at best.

The preceding week I had been under a ton of stress and was very worn down. Immediately after the exertion, I became weak, dizzy, nauseated, pale and cool, hypotensive with 80's systolic, weak pulses, and the Medic onscene said I was bradycardic (don't know what rate).

The EMS crew didn't feel the need to do a 12-lead. They gave me a NRB and I was fine after about 15mins. It was a first time event and never experienced that before so not totally sure what happened. I suspect that the high level of stress and body being completely worn down for the past week was a factor.

So yeah, exertional states can produce presentations like the patient's in this scenario.

 

[Handsome Robb]

At the point I'm at in my education and experience level I think I would have been quick to pace this patient after ruling out something easily reversible and correcting the hypoxia unless, like someone else said, my partner could have gotten a line faster than we got the pacing set up. Drawing the atropine will take 2 seconds, we use prefills.

 

[18G]

At the point I'm at in my education and experience level I think I would have been quick to pace this patient after ruling out something easily reversible and correcting the hypoxia unless, like someone else said, my partner could have gotten a line faster than we got the pacing set up. Drawing the atropine will take 2 seconds, we use prefills.

Honestly, I think this patient was extremely lucky that the body was able to correct what was wrong without intervention. Any patient with a HR of 34, crackles, hypotension, altered mental status, cool and pale skin, isn't gonna get a, "let's see if this is transient approach".

A 12-lead was absolutely necessary in this patient's care. It's sad EMS didn't have it available.

 

[Handsome Robb]

Honestly, I think this patient was extremely lucky that the body was able to correct what was wrong without intervention. Any patient with a HR of 34, crackles, hypotension, altered mental status, cool and pale skin, isn't gonna get a, "let's see if this is transient approach".

A 12-lead was absolutely necessary in this patient's care. It's sad EMS didn't have it available.

Alright, I don't feel so green now. Thanks I wouldn't be comfortable trying to "wait this one out" based on what was given. Even if the pt was hypothermic I'd start active rewarming and pacing provided they aren't too cold for electricity.

Agreed on the 12 lead. When I first learned about them they seemed like it would take forever to get it setup. Now that I have placed my fair share while working I have realized how quick and easy they are.

So my thoughts are after initiating ACLS on this PT I would want to listen to lung sounds again as well as a bp. Provided the lungs cleared up a bit I would be leaning towards a bolus of warm saline, but maybe that's me being all giddy about our new NS bag warmers h34r: I don't see a pressor being high on my list unless fluids + pacing aren't doing the trick. If fixing her perfusion problem hasn't fixed the level of consciousness I'd be headed towards an ETT.

Be gentle

 

[systemet]

I had a very similar episode happen to me during some exercise which was only moderate at best.

Then, with respect, I'd suggest you might want to chat with your family MD, and get an ECG. Seriously.

If you do VO2max tests on people, and they get their heart rate up to 200/min, and then pass out, this makes some sort of sense. But becoming unconscious and bradycardic to 35/min, bradypneic, as described by OP, quite possible after having some sort of seizure episode (Stoke-Adams syndrome anyone?), is not a normal response to moderate exercise.

The preceding week I had been under a ton of stress and was very worn down. Immediately after the exertion, I became weak, dizzy, nauseated, pale and cool, hypotensive with 80's systolic, weak pulses, and the Medic onscene said I was bradycardic (don't know what rate).

Then you have something else happening. Maybe you're sick, maybe there's an electrolyte issue, maybe you've just discovered some cardiac pathology, and the exertion is unmasking all of this. But this is not a normal response to exercise.

The body is adept at preventing us from overexerting ourselves. We maintain normal pH and PCO2 until we reach our lactate threshold, and even for a fair while beyond. Even with maximal exercise normally healthy people don't even approach the beginning of cardiac ischemia, despite cardiac output being the limiting factor.

People shouldn't just pass out because they're exercising. When this occurs it's because of something else. It should be taken seriously, it should be evaluated, and doing otherwise is lazy and incompetent. There is something else happening here, ranging from the benign anxiety syndrome precipitated by getting a mild sense of dyspnea while exercise to something more severe.

The EMS crew didn't feel the need to do a 12-lead. They gave me a NRB and I was fine after about 15mins. It was a first time event and never experienced that before so not totally sure what happened. I suspect that the high level of stress and body being completely worn down for the past week was a factor.

Those probably were, but dude, you should go talk to your doctor. Are you sure you don't have a high risk ECG?

So yeah, exertional states can produce presentations like the patient's in this scenario.

Only in that exertional states can unmask underlying pathology. The healthy human body doesn't decide to throw you unconscious and desaturate you because you played a little broomball. This is not normal physiology.

 

[systemet]

Honestly, I think this patient was extremely lucky that the body was able to correct what was wrong without intervention. Any patient with a HR of 34, crackles, hypotension, altered mental status, cool and pale skin, isn't gonna get a, "let's see if this is transient approach".

It's amazing how many things get fixed by the time it takes to move the patient to a decent environment and gain IV access though.

It's hard to make these judgments without being there, but given how many syncopal events are self-limiting, I wouldn't be jumping on pacing until I have any hypoxia corrected.

If you believe that the altered mental status is caused by hypotension from the bradycardia, then pacing is appropriate. This is a definite possibility in this patient, with a familial cardiac hx.

A 12-lead was absolutely necessary in this patient's care. It's sad EMS didn't have it available.

Agreed. It would be nice to see if there was any signs of infarction, Brugada syndrome, HOCM, etc. Even a 3-lead would be nice to see if this is just sinus bradycardia, or if we have some sort of AV block occurring (which would bias us right towards pacing).

 

[18G]

Then, with respect, I'd suggest you might want to chat with your family MD, and get an ECG. Seriously.

If you do VO2max tests on people, and they get their heart rate up to 200/min, and then pass out, this makes some sort of sense. But becoming unconscious and bradycardic to 35/min, bradypneic, as described by OP, quite possible after having some sort of seizure episode (Stoke-Adams syndrome anyone?), is not a normal response to moderate exercise.



Then you have something else happening. Maybe you're sick, maybe there's an electrolyte issue, maybe you've just discovered some cardiac pathology, and the exertion is unmasking all of this. But this is not a normal response to exercise.

The body is adept at preventing us from overexerting ourselves. We maintain normal pH and PCO2 until we reach our lactate threshold, and even for a fair while beyond. Even with maximal exercise normally healthy people don't even approach the beginning of cardiac ischemia, despite cardiac output being the limiting factor.

People shouldn't just pass out because they're exercising. When this occurs it's because of something else. It should be taken seriously, it should be evaluated, and doing otherwise is lazy and incompetent. There is something else happening here, ranging from the benign anxiety syndrome precipitated by getting a mild sense of dyspnea while exercise to something more severe.


Those probably were, but dude, you should go talk to your doctor. Are you sure you don't have a high risk ECG?

Only in that exertional states can unmask underlying pathology. The healthy human body doesn't decide to throw you unconscious and desaturate you because you played a little broomball. This is not normal physiology.

Actually, I have felt similar to this episode many, many years ago when I experienced heat exhaustion which is why I am summing it up to over exertion in the presence of being really worn down.

I had an echocardiogram done a few weeks prior to this because I asked my PCP for it based on a 12-lead finding I noted on myself. The echo was normal.

 

[systemet]

Actually, I have felt similar to this episode many, many years ago when I experienced heat exhaustion which is why I am summing it up to over exertion in the presence of being really worn down.

I had an echocardiogram done a few weeks prior to this because I asked my PCP for it based on a 12-lead finding I noted on myself. The echo was normal.

I'm glad you've had this evaluated, at least partially. I think I'm starting to stick my nose a little too far into what's your business and not mine.

Let me apologise if I came across as too dogmatic about this. I just want to make sure it's clear for any basic providers reading this thread that passing out during exercise = pathology until proven otherwise.

 

[18G]

I'm glad you've had this evaluated, at least partially. I think I'm starting to stick my nose a little too far into what's your business and not mine.

Let me apologise if I came across as too dogmatic about this. I just want to make sure it's clear for any basic providers reading this thread that passing out during exercise = pathology until proven otherwise.

No need to apologize. I certainly welcome your insight and appreciate your input on my little episode and the OP's scenario.