Wtf was happening with this pt?

[the_negro_puppy]

Went to a call early this morning of a 40 y.o M who had fainted/collapsed after going to the toilet around 3am.

When we arrived he was upstairs laying on his side in bed. He was a little clammy and pale and said he had to lie down because he felt like fainting. Gentleman had no significant medical hx, except for a similar occurrence 1 year earlier and recently some liver problems/elevated liver enzymes, also suffered from narcolepsy. Nor regular meds.

Initially this guy was hr 82, Sp02 99% and BP 99/70 is. GCS15, denied any pain, SOB etc.

Upon 3 lead ECG his rhythm was initially sinus at a rate of around 80. At this stage he asked if he could move from his side onto his back. As he moved his HR suddenly dropped to brady around 30-40bpm, this was captured on ECG. It remained brady fro several mins with pt stating he didnt feel any different. As the pt moved again his HR returned to 80, and then when he would move it would go back down to brady between 30-40. During this time his BP started to drop and went as low as 70/40.

We got IV access, put on 02 and did a 12 lead which other than bradycardia had no ST elevation or other ectopies. We also called for ICP backup (they have atropine) and raised his legs. Gave him IV saline which brought his BP back up to around 100 systolic, but he kept going between a normal HR and bradycardic, complaining of feeling like fainting and 'lying down'.

Ended up stair chairing him and taking him to hospital with his BP remaining around 110 and his HR anywhere between 40-45 and 80. Atropine was drawn up but not used. Pt afebrile, BSL good.

Does anyone have any idea what might have gone on with this gentleman? I am truly stumped.

 

[LonghornMedic]

Sounds like it may have to do with his vagus nerve. By your description it seemed to happen with some exertion and all of his symptoms add up to an issue with his vagus nerve. There are various reason why, such as an infection. Probably a call you won't see very often.

 

[firetender]

Let's dig in to the vault!

Delayed recovery from Vasal-Vagal response.

Textbook re: 3 a.m. poop and then down. Lucky pt.! Actually made it to a bed. The delayed recovery could be an indication of a previously undetected pathology emerging, or the patient is overall weak.

This was a Relatively common cause of death in retirement trailer parks in FL back when. So much so we called them "blowing a gasket on the bowl."

Straining at stool stimulates the vagus nerve, slowing the heart and suddenly dropping the blood pressure. Pt. loses consciousness, slumps forward, collapses to floor. The death is often due to airway obstruction as a result of hyperflexion of the neck from landing on the head. Patient awakens, but in a compromised position (butt up, pinned to the bowl) and weak, is unable to maneuver out of position in time to prevent asphyxiation.

Interested in learning if anything new on this has come about.

 

[clibb]

Did you get a look at his stools from when he went to the bathroom?

Sounds like a GI Bleed to me.

 

[LonghornMedic]

Did you get a look at his stools from when he went to the bathroom?

Sounds like a GI Bleed to me.

Huh? :unsure:

 

[the_negro_puppy]

Thanks for the replies, but to be hinest, Im not sure if he made it to the toilet, anf ihe he did, if it was number 2! :0

 

[clibb]

Huh? :unsure:

What was confusing about what I just said?
You do know what stools and GI Bleed is right?

If you don't you should google it.

Actually, I did it for you:
http://www.emedicinehealth.com/gast...ge3_em.htm#Gastrointestinal Bleeding Symptoms

Thanks for the replies, but to be hinest, Im not sure if he made it to the toilet, anf ihe he did, if it was number 2! :0

You just stated above that he did.

Went to a call early this morning of a 40 y.o M who had fainted/collapsed after going to the toilet around 3am.

Got to have these stories straight, especially for narratives.

 

[the_negro_puppy]

What was confusing about what I just said?
You do know what stools and GI Bleed is right?

If you don't you should google it.

Actually, I did it for you:
http://www.emedicinehealth.com/gast...ge3_em.htm#Gastrointestinal Bleeding Symptoms



You just stated above that he did.



Got to have these stories straight, especially for narratives.

Well i guess I got the tense wrong. He got up of bed and was on his way (going) to the toilet when he had the syncope.

 

[LonghornMedic]

What was confusing about what I just said?
You do know what stools and GI Bleed is right?

If you don't you should google it.

Actually, I did it for you:
http://www.emedicinehealth.com/gast...ge3_em.htm#Gastrointestinal Bleeding Symptoms



You just stated above that he did.



Got to have these stories straight, especially for narratives.

Sounds nothing like a GI bleed to me. But that's my opinion.

 

[Akulahawk]

Timing may be the key with this one. Getting up and having a syncopal event along with the vitals you're telling us about may mean something other than a vasovagal event is happening.

To me, this guy isn't dehydrated... though he is in shock. Now his bradying down may be from vagus stimulation. When he brady'd down, was there any change in the ECG aside from the rate?

Any chance he's having a NSTEMI?

As to a GI bleed, they usually have a very distinct odor...

 

[CAOX3]

Bump in his liver enzymes?

Ruptured esophageal varices, possibly in the stomach.

Can I have my prize now.

 

[JPINFV]

Bump in his liver enzymes?

Ruptured esophageal varices, possibly in the stomach.

Can I have my prize now.

Could be. Can I get Social History for 1000 Alex?

 

[CAOX3]

Could be. Can I get Social History for 1000 Alex?

Yes you can,

The negro puppy can we get a social hx for a 1000 please?

I hope its a daily double.

 

[8jimi8]

Bump in his liver enzymes?

Ruptured esophageal varices, possibly in the stomach.

Can I have my prize now.

the patient would be vomiting BRB if it was significant bleeding of varices

 

[MrBrown]

Sounds vagus related if you ask me

Where is Dr Rashford when you need him? Probably in a car wreck upside down in a ditch intubating some bloke over the other side of town ....

 

[rhan101277]

When the rate changed was there any difference in the QRS width?

It is possible that his SA node was not working properly or poorly perfused. Also 12 leads are not 100% accurate for detecting MI's.

It is possible it was a vagal episode. There are lots of possibilities. Just do your best to stabilize the patient. I also like to know what is going on, but most of the time it requires comprehensive testing and people that know way more than we do.

 

[Outbac1]

Sounds like a vagal response to me. Did you palp his pulse to see if it matched the monitor? You should always manually check the pulse especially if the monitor says something funky is going on.

 

[gicts]

I'm with the crowd and believe the vagas is to blame, but did you happen to do an orthostatic BP while waiting for the ICP?

Also, did anyone get the impression it could have been an aneurysm? Perhaps one that is tamponaded by his position? Or is that a little bit of a stretch?

 

[the_negro_puppy]

This gentleman was a middle class normal 40 year old. No alcoholism or drugs. There were no other changes to the ECG, though his T waves were a little peaked, they were not higher than half of the QRS.

Pt had no cardiac hx and SOB or chest pain.

 

[Jay]

I was thinking a bleed at first as others suggested however the PT went straight into decompensating which suggests a vagal response rather than some alternate form of shock. The facts also don't suggest shock because his vitals, for the most part look good. If you wanted to look deeper into the EKG we can rule out possible MI/STEMI (no ST segment elevation per se, no blocks present, etc.) and could potentially treat with dobutamine as a first line drug for the brady and hypotension. Though unlikely, he is narcoleptic and sudden sleep may cause the drop in his BP as well, this may mimic a vagal response. I would still have checked the stool for the black tar like color that would be indicative of a bleed to be safe and even though his SpO2 looks good would still do 4 or 6 LPM via cannula to be safe in case there is shock present. During transport would check vitals every 5 and see if there is anything pointing me in any other direction. Without additional Hx this is all that can be done in my humble opinion...

By the way, why no Hx???

It is an interesting case.