Case of the Month
July 2004

72-year-old female — syncope at the bingo hall

You’re dispatched to the local bingo parlor for a reported “elderly female with a syncopal episode.” While en route the dispatcher notifies you that the RP states CPR is now in progress on the patient and they are upgrading to a medic response. You arrive to find the patient supine on the floor being attended to by several bystanders. The patient is awake and appears alert, she is pale and profusely diaphoretic and appears to be breathing normally. You note her skin is very cold and clammy and her radial pulse is very weak and slow at about 46 beats per minute. Bystanders report that she suddenly collapsed without warning while seated at a table and was found to be pulseless and apenic. She received about a minute of chest compressions and ventilations before regaining consciousness. The patient reports she had a brief episode of “fullness” in her chest followed by syncope. She currently has no pain but feels very weak, dizzy and nauseated. Based upon this initial information, you declare the patient SICK!

You update the responding medic unit with your initial findings of no CPR and request they continue due to your patient’s SICK status. You begin administering high flow O2 via non-rebreather mask while your partner obtains initial set of vitals: blood pressure 144/76, pulse rate 46, weak and regular, respiratory rate of 16 and pulse oximetry reading of 98%. The attached EKG monitor shows a bradycardic NSR without ectopy. Lungs are clear and equal to auscultation. Your SAMPLE history is as follows.

S	—	Awake and alert, bradycardic w/normal BP, profusely diaphoretic, c/o weakness, dizziness and nausea. No pain at this time.
A	—	No known allergies
M	—	Analapril (HTN) Lipitor (cholesterol)
P	—	Hypertension, high cholesterol, 2 packs per day smoker x 20 yrs.
L	—	Coffee and toast for breakfast (2 hrs ago)
E	—	Feeling fine playing bingo when experienced brief episode of “fullness in chest" followed by the collapse.

You continue to monitor the patient’s status and provide oxygen. Her status remains unchanged until the medics arrive upon which the patient’s dizziness and nausea increase and she begins to vomit. Her airway is easily managed with suctioning. The medics perform a 12-lead EKG that confirms your suspicion of an ongoing and evolving MI. You assist the medics with treatment and package the patient for transport. She is safely delivered to the closest appropriate ER.

Syncope
Syncope is defined as a temporary loss of consciousness due to an interruption or decrease in blood flow to the brain. The causes for syncope are many and often not critical. But, it is important to remember that syncope can be a sign of serious illness as demonstrated in this case. Even in the absence of ongoing chest pain, the patient’s complaints of weakness, dizziness and nausea, as well as her bradycardia and profuse diaphoresis led the EMTs to make the proper decision of SICK, ensuring the patient received the proper level of care.

The lesson from the case: There are many causes of syncope, many of which that are non-critical. But, syncope can often be the presenting sign of a serious and life-threatening illness. It is up to EMTs to closely pay attention to the sometimes subtle complaints that accompany an atypical cardiac event such as this. Quick and early recognition of the SICK patient is essential to providing proper care and influencing good outcomes. Additionally, the symptoms of acute coronary syndrome (MI) are often atypical in woman and elderly patients. This patient did not have the “classic” signs of acute coronary syndrome.

View optional info on syncope — Merck.com (external link)