Case of the Month
May 2007

67-year-old female, syncope

Dispatch
"Aid 5, Medic 2, 67-year-old female – syncope, now conscious”

While en route the dispatcher advises you that the patient’s son is at her side and she is now conscious and speaking to him. 

Scene Size-up
You arrive at the patient’s home. Her son greets you and states that his mother was in the bathroom when he heard a crash and a thump. He leads you into the bathroom where she is lying on the tile floor. She is conscious but confused and appears pale and mildly diaphoretic. There are no obvious signs of trauma.

Initial Assessment
The patient’s skin is slightly pale and mildly diaphoretic. She has an irregular radial pulse of 48/min and a blood pressure of 96/P. She is breathing with ease at 20/min and is confused about the event but currently knows where she is. She states that she was standing in front of the bathroom sink and all she remembers is waking up on the floor…she continues to ask “what happened to me?”

Initial Treatment
You decide that the patient is SICK based on nature of illness (NOI), mental status, radial pulse and skin signs. You direct your partner to initiate high-flow oxygen utilizing a non-rebreathing mask. A medic unit is updated and you send your third crewmember to the rig to bring up the stretcher.

Event and Recent History
Further questioning reveals that the patient is being treated for cardiac dysrhythmias and has worn a Holter monitor (see below for more information on Holter monitors) to document her cardiac rhythms. She states she was getting ready to go shopping and, while putting make-up on in front of the sink, she must have fainted. She only remembers waking up on the floor. 

Further Evaluation and Treatment
Secondary vital signs, glucometry (116 mg/dl) and oximetry (97% with non-rebreather) are performed. The patient is found to have a repeat blood pressure of 92/60 and a heart rate of 48/min, yet when the EMTs attach the cardiac monitor to view her rhythm the reading is 72/min…ALS is updated. Your crew finishes with a brief trauma exam before taking the patient downstairs to meet the ALS unit that is waiting in the street. ALS starts an IV line, performs a 12-lead ECG that confirms multiple PVCs, starts their treatment plan and transports the patient to their local control hospital.

In the ED the patient is confirmed to have a significant cardiac dysryhthmia (multiple PVCs) most certainly causing syncopal episode (commonly referred to as cardiac syncope).

Syncope
Syncope is defined as a transient self-limited loss of consciousness, usually leading to a fall. It is a subset of a broader range of conditions causing transient loss of consciousness. Syncope is a common medical problem accounting for many emergency department visits and is the sixth leading cause of hospitalization for people over the age of 65.

Cardiac Syncope
Inside the heart, premature ventricular contractions (PVCs) are triggered in an area outside the usual AV node conduction pathway. PVCs are characterized by premature and bizarrely shaped QRS complexes usually wider than 120 msec. These complexes are not preceded by a P-wave. The T-wave is usually large and its direction is opposite the major deflection of the QRS complex.

Symptoms pertinent to the management of the PVCs are those that suggest underlying ischemic cardiac disease, such as chest pain or its anginal equivalent, or those suggesting hemodynamic compromise, such as lightheadedness or syncope.

• Patients are usually asymptomatic post event
• Patients may report feeling that the heart "stops" after a PVC
• Patients with frequent PVCs or bigeminy (two PVCs in a row) may report syncope. This symptom is due to either inadequate stroke volume or decreased cardiac output caused by the condition effectively halving the heart rate.

Holter monitors are useful in quantifying and characterizing ventricular ectopy or other arrhythmias.

• Holter monitors are small monitors that stay with the patient for a given period of time (often 48-72 hours) and are attached by simple stick-on external leads.
• They also have been used to determine treatment efficacy in patents with frequent or complex PVCs.
• More than 60% of healthy, adults greater than 60 years of age have occasional ventricular ectopy during Holter monitoring.

View more information on Holter monitors and photo
Wikipedia (external link)