Wtf was happening with this pt?

vasovagal syncope

definitely vasovagal syncope from pushing. so many nursing homes so little time...
 
As the esteemed late Dr Harold Klawans wrote in his book "Defending the cavewoman: and other tales of evolutionary neurology" this is a pretty regular occurance of middle aged to older men who have to rely on the Valsalva manuever to order to void.

There was a really sad story of a literature professor who caused his BP to raise to much that he stroked out and took with it the reading center on the right hemisphere. He could no longer read from left-to-right.

I am going to guess Vagus nerve involvement from the fellow using Valsalva or orthostatic BP change.
 
R a c h e l said:
definitely vasovagal syncope from pushing. so many nursing homes so little time...
Click to expand...

Indeed but this guy was 40 :P



In other news cot called to a 63 y.o F 10/10 crushing L) side chest pain radiating down L) side. BP initially 110/74. Pt extremely diaphoretic, SOB, skin cold.

12 Lead ECG showed paced rhythm with global S-T elevation and LBBB
All the nursing home staff could give us was a medical sheet saying hx of pacemaker and AF (+asthma and a few others). Te,p 35.9 Sp02 99% room air. Pain increased on inspiration and movement.

Lights and sirens to hospital. Withheld aspirin- (pt said it triggers asthma attack). Second BP around 100. Withheld GTN.

2.5mg IM morphine given (no effect) iv access made, then 2.5mg IV morphine (no effect)

At hospital they said they werent sure what was going on,b ut were treating for sepsis. Pt temp 35.8 at hospital with pain remaining. An old ECG from her hospital file revealed that the global S-T elevation and LBBB were 'normal' for her.
 
IM morphine? I thought that went out of fashion with bell bottoms and eight tracks

As for sepsis I dno .... hypothermia is often a sign of low cardiac output and this lady was on the low side of normotensive or the high side of hypotensive at 100 systolic so .... oh bugger this, where is Dr Rashford, that dream medical director, when you need him? :D

Come to think of it he is probably at the hospital, which is where the patient needs to go to.
 
MrBrown said:
IM morphine? I thought that went out of fashion with bell bottoms and eight tracks

As for sepsis I dno .... hypothermia is often a sign of low cardiac output and this lady was on the low side of normotensive or the high side of hypotensive at 100 systolic so .... oh bugger this, where is Dr Rashford, that dream medical director, when you need him? :D

Come to think of it he is probably at the hospital, which is where the patient needs to go to.
Click to expand...


lol. IM morphine was given due to failed IV access.

Her by was 110 systolic, then around 100 then a few around 140-150.

Pt had been to hospital 1 year earlier for a 'similar' even the nursing home staff said. This event was apparently a UTI that caused her sepsis. Pt also had an acquired brain injury/ which is why she was 64 and in high care.

Ill see if i can post ecg strip tomorrow
 
the_negro_puppy said:
Indeed but this guy was 40 :P



In other news cot called to a 63 y.o F 10/10 crushing L) side chest pain radiating down L) side. BP initially 110/74. Pt extremely diaphoretic, SOB, skin cold.

12 Lead ECG showed paced rhythm with global S-T elevation and LBBB
All the nursing home staff could give us was a medical sheet saying hx of pacemaker and AF (+asthma and a few others). Te,p 35.9 Sp02 99% room air. Pain increased on inspiration and movement.

Lights and sirens to hospital. Withheld aspirin- (pt said it triggers asthma attack). Second BP around 100. Withheld GTN.

2.5mg IM morphine given (no effect) iv access made, then 2.5mg IV morphine (no effect)

At hospital they said they werent sure what was going on,b ut were treating for sepsis. Pt temp 35.8 at hospital with pain remaining. An old ECG from her hospital file revealed that the global S-T elevation and LBBB were 'normal' for her.
Click to expand...

the_negro_puppy said:
lol. IM morphine was given due to failed IV access.

Her by was 110 systolic, then around 100 then a few around 140-150.

Pt had been to hospital 1 year earlier for a 'similar' even the nursing home staff said. This event was apparently a UTI that caused her sepsis. Pt also had an acquired brain injury/ which is why she was 64 and in high care.

Ill see if i can post ecg strip tomorrow
Click to expand...



Pnuemosepsis? Pleural effusion? I don't think I would have gone down the ACS thought process any further than considering it as a possibility.

Am I correct in my thinking that T-wave morphology is not useful at all in a paced rhythm? I thought that since there was an artificial stimulus for the depolarization, you can expect a wide, bizarre complex on the monitor.
 
Paced and LBBB rhythms typically have wide bizarre looking complexes w/ discordant T waves. If I'm remembering this correctly, If the T wave is > 25% of the QRS complex, it's suspect. Also if the T waves are concordant it's suspect.


Paging Tom B ....
 
Sounds like vasovagal phenomena related to a GI bleed. Vasovagal phenomena can be a non-specific symptom of upper GI bleeds. This guy has some liver disease which puts him at high risk for bleeding. The fact that he responded well to some fluid supports a hypovolemic hypotension. (Complicated by the vagal induced bradycardia).

His VS weren't really that stable at all. He was hypotensive to start with and feeling light headed and had no reserves to compensate for the bradycardia so became even more hypotensive.

Every time he moved onto his back or laid flat he stimulated the vagus nerve. Best positions for these patients are side-lying or sitting up.
 
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