Syncope

Old woman has a syncopal episode at the dinning room table. No prior history. The family says she was out 1-2 minutes. Her eyes rolled back into her head and she vomited. Can’t determine whether she vomited and then passed out or passed out and vomited.

She looks terrible, although she is alert. She says she feels weak, but she doesn’t want to go to the hospital. Despite her age she had no significant medical history and lives independently. Her pressure is 120/70. Here is her strip:

I tell them in any unexplained syncope, it is important to go to the hospital. I can understand how given the dinner occasion, she might not want to go. I am thinking this is a vasol vagal episode. I want to do orthostatics, just to see what happens, but she says she is too weak to stand. And then she is unresponsive and vomits again. Unfortunately the leads have come off due to her sweaty skin, but I manage to get new leads on all the while supporting her airway, and hoping she doesn’t code. Here is what I capture:

She wakes up and her rythm goes back to this:

We still insist she go to the hospital. With the help of her granddaughters, I get her out of her vomit drenched blouse and into a hospital gown, which I carry on the stretcher with the sheets.

We go on a non-priority. I put her on some 02 and put in an IV as we drive. Her color is much better. I get her demographic information, and then go to call the hospital. Right when I get ready to patch, I glance at her and she is vomitting again. I give a quick patch, “Sorry, my patient just started vomiting and is bradying down. Bottom line syncope at the dinner table. Be there in 5 minutes.”

I hit print on the monitor while I try to keep the vomit in the small garbadge pail I grabbed and off her face. The episode isn’t as long as the others and I can’t say she is unresponsive during it. We are already at the hospital now. I have her cleaned off, and we take her in.

I give the report, and then write my run form. When I see the doctor, he shows me her 12 lead. The computer printout says possible posterior MI, although it doesn’t jump out at me, and I’m not certain I agree. I show him my strips, and tell him this is what she was doing when vomitting, although she appeared normal at other times.

And then I look closely at the strip I recorded during the last vomiting episode. Here the ST is clearly elevated, but only for a few beats.

Its odd, but maybe what happens to her is similar to what happens when someone gets ST elevation during a stress test. She has a near blockage perhaps, which occludes during the stress of vomiting or is spasming. I’m not really sure.

I was surprised afterward that I didn’t do a 12 lead myself and wish I had. I normally always do. I was just sort of busy, and I guess I was just thinking it was all a vagal episode and/or an upset stomach, but maybe it was an MI, and so was lower on my priority list. I think I might have done one in the house if there hadn’t been so many firefighters and police offiders standing around the patient. I could have asked them to leave. Not that as health care providers, they shouldn’t be involved, just having so many people — firefighters, cops or medics makes it more awkward for the patient.

I’ll post more later on this case when I next see the doctor and I can get more information.

I have also noticed that it is easier to study a strip after a call, than during one. It is hard to pick out subtleties unless you really study the strip. I think I should also have said to myself — the irregular beats while she was vomiting are not typical of vagal episodes, at least in my experience.

I had another interesting call the same day, which I write about in my November log on my Capnography for Paramedics web site. It is another call where things aren’t always what they may appear at first glance.

Hypoventilation not Hyperventilation

8 Comments

  • Anonymous says:

    What’s your take on that second rhythm strip? I am not seeing what’s going on there. Here’s what I see:Couplet beats, no p wave. Then there’s some p-wave dissociation going on towards the end 2/3 of the strip. It’s like it’s a junctional rhythm with PJCs. But there’s also some ST elevation with the second beat in the couplets. I don’t know. I’m curious to hear your take.

  • F says:

    Interesting case! What is your feeling on using 3 lead ECGs for diagnostics like this? You mentioned ST elevation, but the 3 lead you referenced I assumed was at a non-diagnostic quality, as 3 leads usually are. If we are discussing changes of this nature on these strips, I suppose the Q waves present are of note as well.3 leads are good for rate + rhythm though, for sure: and that 2nd strip is a weird one. Looks like some sort of junctional bigeminy. You think maybe the woman dropped her pressure here as well, causing the syncope?I know what you mean about looking at EKG strips during vs. after calls. The picture is always so much clearer in retrospect. I guess the goal is to do enough of these so that slow, careful consideration of the details is instead replaced by rapid syndrome recgonition followed by immediate treatment. Kinda takes an ounce of fun out of it, doesnt it?

  • PC says:

    I am very perplexed by this ECG. I wish I had a longer and cleaner strip. The problem is when I am recording it, the patient is actively vomiting so the movement can interfere with the strip. I have never seen the elevation on one or tewo beats and then not on the next, unless it is caused by artifact/movement, but the elevations appeared more than once so I tend to think she was undergoing second by second changes in her heart.I should have done a 12 lead in the house. I’m kicking myself for not doing one either there or in the ambulance. As I mentioned I didn’t in the house due to all the responders present in the room, the family around the formal dinner table and the old woman not really wanting to get up. Once she vomited the first time, I focused in on the bradycardia which was confirming my impression that she had vagaled caused by the vomiting. I saw the couplets, put didn’t really process them. Then the fire department was anxious to leave, but I wanted to them to stay until I got her out fo the house just in case she coded, because witnessing the unresponsiveness during the vomiting made me uneasy. So we loaded her and then dismissed fire. I told my partner I was all set, thinking I had time to do all I needed to between the house and the hospital — 02, IV, labs, demographics, radio patch, and maybe 12 lead when I thought of it.The IV blood came a little slow, and then when I was patching she started throwing up again, and that took up the rest of my time.As far as the diagnostic setting, you can get diagnostic in the 3 lead when you print if you configure your monitor to print in diagnostic.When I am in the city, I work in a different car with a different monitor every day, but I believe most are set for the 3 lead to print in diagnostic.I wasn’t even thinking about it though because the ECG looked so normal to me — at least when she wasn’t vomiting.All in all a strange, interesting call and strip that goes to show, you need to be thorough with every patient and that you shouldn’t jump to conclusions like I did. Assuming vagal and not really considering a possible MI, which is not to say it wasn’t a vagal and not an MI.I hope to see the doctor soon and ask what the outcome was.Thanks for the comments

  • Jamie Davis, the Podmedic says:

    Peter, I agree with your take on reading strips better after a call. It seems like I always pick up on something that I didn’t see the first time around. As far as the twelve lead, sometimes we all get in the mindset of going down a certain diagnostic path. Once we do (and we all do this), switching gears and looking at the problem from a different direction is one of the hardest things to do. An instructor once told me that if you do a twelve lead on any non-specific problem from nose to navel, you pick up on the cardiac patients that present in a non-traditional way.

  • Anonymous says:

    Regarding the 12 lead, we learned to do a 12-lead for people with a problem from knees to nose.

  • PC says:

    Thanks for the comments. A couple days later I had an old lady who passed out at church. She did not want to go to the hospital. I insisted and she ended up agreeing to go. I did the 12-lead. No MI this time.

    There are few things better than picking up an MI or an unexpected sugar problem through just doing your general best practices. I hate when I slip and miss something.

    Our 12 lead protocol, which I wrote for the region includes the following:

    Indications:

    Any patient suspected of acute coronary syndrome, including any of the following:

    1. Chest pain, pressure or discomfort
    2. Radiating pain to neck or left arm. Also right arm, shoulder or back
    3. Dsypnea
    4. CHF
    5. Cardiac Arrythmias
    6. Syncope/near syncope
    7. Profound weakness
    8. Epigastric discomfort
    9. Hyperglycemia in diabetic patients
    10. Sweating incongruent with environment
    11. Nausea, vomiting
    12. Previous cardiac history or other cardiac factors

    Before and after any rhythm conversion including PSVT and rapid afib.

  • Anonymous says:

    I am not a medical professional. I just happened to be looking around for Vaso Vagal syncopes on the web as I suffer for them. I am a 29 year old male in very good health with an abosulte unreasonable fear of needles and blood in a hospital setting. I have seen a very close copy of the second ECG chart only it was a printout during one of my episodes. Everytime I have a physical or see a person get jabbed with a needle I pass out. When I was 18 I did it in a hospital, I had suffered a mild concussion during a football game and was in for observation. My blood pressure upon arriving was 115/70 with a pulse of 65. This was normal for me. They hooked me up to a machine with leads on my chest as well as a gave me an IV. As soon as the IV went in I was out within 10 seconds. I was told my heart stopped for ~10 seconds during my spell. After the 10 second flatline my rythem went to this very odd one very close to the one shown in the second chart. When I came to my after about 30 seconds my rythem went completely back to normal. I was exrtemely sweaty and very fatigued for about 20 minutes after this happened. I was diagnosed later as having a vaso vagal syncope. One doctor went as far as recommending a pace maker to prevent it in the future. I had agreed to the operation but passed out when having some blood work done and the external pacemaker did absolutley nothing to prevent the same thing from happening.

  • Bill says:

    I found some interesting information about Syncope here. Check it out!

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