Case of the Month
November 2006

25-year-old female—syncope

Dispatch

"Aid 17, Medic 18 to a 25 year old female, syncope"

En route your crew discusses the following considerations:

• Reasons for syncope
• Other reasons for apparent syncope (seizure, trauma, pregnancy-related issue, etc. )
• Potential injuries from a fall after fainting

While en route the dispatcher updates you stating the patient is now awake.

Scene Size-up
You arrive at the home of a young couple. The boyfriend states he was in the bedroom when he heard a crash in the bathroom. He went in and found the patient unconscious on the floor and turning blue. She then started looking better and coming around. He states she still looks ‘pasty’.

Your team finds the patient leaning up against the bathtub; she is pale and mildly diaphoretic. A quick trauma exam finds no injuries or complaints of pain. The patient is moved out into the hallway. Her color is improving.

Initial Assessment
The patient appears mildly lethargic but answers questions appropriately. She states she went into the bathroom and suddenly found herself on the floor with her boyfriend panicked looking down at her; he then called 9-1-1.

Your partner completes an initial assessment:

SICK or NOT SICK?
Based on what you see so far, would you consider this patient SICK or NOT SICK? What steps will you take based on the direction you choose?

• Types of treatment needed for this patient?
• Further steps for evaluation?
• Need for ALS care?

Initial Treatment
You decide that the patient is SICK based on syncope, altered LOC, skin signs and irregular heart beat.

You apply a non-rebreather mask at 8 liters per minute and continue your assessment. The medics are updated.

Physical Exam
Your partner gives you the following information:

SAMPLE

Second Set of Vital Signs

As you are evaluating the patient she suddenly becomes very lightheaded again and almost passes out. You elevate her legs and feel her pulse. Her heart rate has become threadier and more irregular. Her skin color has become more pale and she is now sweaty. Her blood pressure is about 50/p. After a few moments she shows signs of improvement and her pressure comes back up to 94/P. Her heart rate is still irregular. You update the medics and prepare her for transport.

The medics arrive and place the patient on a heart monitor. She is found to be in a normal sinus rhythm, but she is suffering from frequent, multi-focal PVC’s. After a minute or two one of the medics notices the patient experiences a run of ventricular tachycardia.

An IV is placed in the patient’s arm and she is medicated with an anti-arrhythmic drug ( lidocaine ). The ALS crew transports her to the local ED for further evaluation. The transport is non-eventful.

At the ED she is found to have a very low potassium level. Although more testing is needed, it is thought that this may have contributed to her cardiac arrhythmias.

Syncope is the medical term for a loss of consciousness due to decreased blood flow to the brain. It is referred to, by the public, as fainting, passing out, falling out, and other terms. Other common causes of loss of consciousness such as trauma, seizure, and low or high blood sugar are not considered to be syncope. Syncope accounts for 1 in 20 to 1 in 30 emergency room visits.

There are several causes of syncope. These include, vasovagal reactions, dehydration, medication reactions, and episodes that are cardiac related.

A vasovagal reaction occurs when the major nerve of the parasympathetic system is stimulated causing the heart to slow down and vessels through out the body to dilate. This stimulation can be caused by urination, defecation, swallowing, coughing or fear, to name a few. Classically a vasovagal reaction is usually preceded by one or more of the following: feeling of dizziness, nausea, and or weakness. The treatment is to make the patient comfortable and eliminate any other, more dangerous reasons for the syncopal episode. Any patient that has a syncopal episode must also be evaluated for trauma if the episode leads to any sort of fall. Vasovagal episodes are usually self correcting. Vasovagal episodes account for about 25% of syncope cases.

Dehydration can occur due to excessive vomiting, diarrhea, lack of fluid intake and for other reasons. Treatment of this type of syncope includes keeping the patient supine, administering oxygen, and re-hydration. How the patient becomes re-hydrated is a question of triage. Very minor cases can be handled with oral intake while more severe cases might require placement of an IV line and volume expansion such as Lactated Ringers or Normal Saline. Often a patient that shows signs of dehydration in the field, and who is comfortable when laying flat, can wait until arrival at the hospital to receive an IV. As with vasovagal episodes, make sure the patient is not suffering a more severe reason for syncope. These account for about 10% of syncopal episodes as seen in the Emergency Department.

Medication reactions can cause several different reasons for syncope, but of primary concern is overdose of blood pressure medications. Hypertension medications can lead to seriously low blood pressures if not taken properly. Another very serious threat is the mixing of blood pressure medications and many of the drugs used to treat erectile dysfunction. These two medication types, when combined, can cause syncope and a fatal drop in blood pressure. We used to think only of Viagra, but there are now several names we need to be familiar with, both brand name and generic. For example, Cialis and Levetra.

Another extremely dangerous reason for syncope is a cardiac issue. Several problems can lead to cardiac syncope. Heart attack, electrolyte imbalance, leading to arrhythmias, illegal drug use – particularly stimulants, disease or damage to heart valves, and many others an lead to a decreased or loss of consciousness. This is a truly dangerous type of syncope. These problems can affect persons of many different ages. Case study above is bases on a 27 year old female who had an electrolyte imbalance, possibly secondary to bulimia, who suffered 30 minutes of cardiac arrest due to an arrhythmia. She was fortunate enough to survive. Cardiac events account for about 25% of all syncopal episodes. Always include this suspicion when evaluating the individual who has suffered a decreased level of consciousness or has passed out regardless of age!

Syncope is a common, potentially life threatening reason for calling 9-1-1. Thorough evaluation of these patients is critical to their immediate treatment and long term out come. Keep the patient supine, consider the use of oxygen, consider an ALS evaluation, and always evaluate the patient for trauma if any sort of fall was involved. Since the reason for the syncope can be very challenging, if not impossible, to determine in the field, an emergency room evaluation should always be pursued.