Patient Care

Syncopal Patient Exhibits Weird Symptoms

Issue 9 and Volume 39.

Medic 71’s two paramedics have finished their daily station chores and are just sitting down to lunch. The morning had been light, with only one call thus far in the shift. Just as they’re taking their first bites, the overhead tones ring out.

“Medic 71, Medic 71. Respond to 1432 Barczewski Lane in the town of Edgington on an alpha-level response for the 54-year-old female who fell yesterday and is requesting an ambulance today. Respond on the east EMS channel. Time out 12:17.”

Because an alpha-level call is classified as a nonemergency response, the medics take an extra bite of their lunch as they rise to walk out to the truck.

They respond within two minutes, driving without lights and sirens. As they arrive, a sheriff’s deputy waves to them from the door and walks to the ambulance.

“What took you guys so long?” he asks. “You might want to go look at her. I think she’s still breathing but she isn’t conscious.”

The medics grab their airway kit, drug bag and ECG monitor, and hurry into the split-level single-family home.

Once inside, they find the patient sitting on a living room couch. Her eyes are closed and she isn’t moving.

“Ma’am! Ma’am!” shouts one of the medics as he shakes the patient’s shoulder.

She awakes with a start, suddenly opening her eyes and looking around as if frightened. She recognizes her surroundings after a few moments and seems surprised to see
the paramedics.

Her adult children fill in the details. Their mother had been experiencing unexplained losses of consciousness numerous times over the past few days. She would be up and walking one second, and down on the floor completely unresponsive the next. They deny witnessing any seizure-like activity during her episodes and add that she usually becomes fully awake a few seconds after she regains consciousness.

Hearing this, the patient chimes in, “I fell down the stairs yesterday. One minute I was carrying a basket full of laundry down to the washer, and the next thing I knew I was lying in a heap at the bottom of the stairs. It’s the strangest thing.” She continues, “I’ll just be doing normal things, then I feel like there’s a waterfall in my chest—and then I wake up.”

One of the paramedics assesses the patient while the other gathers further information and other patient history. She’s found to be normotensive, with a blood pressure of 132/78 and a strong radial pulse rate of 86. Her skin is pink, warm and dry, and she passes a Cincinnati Prehospital Stroke Scale exam without showing any neurological deficits.

Figure 1: Patient’s ECG strip

Patient's ECG strip

Patient's ECG strip

 

The rest of her physical exam is unremarkable with clear lung sounds, a soft and non-tender abdomen, no visible trauma and a blood sugar reading well within normal limits at 136 mg/dL. The patient denies any symptoms after her assessment and states she feels completely normal. She doesn’t have any significant medical history and is otherwise in good health. She takes no medications and has no known allergies.

She tells the paramedics she was originally planning to have her husband drive her to the urgent care clinic in town, about 20 minutes away from her house.

“I’d advise against that,” the deputy jumps in. “When I got here she was fine but then she was out … and I mean out out.”

The paramedics convince the patient to accept ambulance transport to the ED for evaluation, advising her that self-transport to an urgent care facility would be unsafe. They place her on a 4-lead ECG as a precaution, which shows a normal sinus rhythm without ectopy, and start a 20-gauge IV attached to a saline lock in the patient’s left arm.

They bring the cot to her side and secure her before wheeling her out of the house. Once she’s loaded, they continue monitoring her vital signs and ECG rhythm, obtaining a 12-lead ECG that doesn’t show any acute abnormalities.

With nothing else to do before they leave and expecting an uneventful transport, one of the paramedics gets into the front of the ambulance to drive to the hospital.

Just as he’s putting on his seat belt, his partner calls to him. “Um, could you come back here for a second? I think she just died.”

The patient said she felt the “waterfall in my chest” feeling again and then suddenly went unresponsive. While she was unresponsive, the paramedic noticed her ECG had changed to a complete asystole with no evident escape beats or other electrical activity visible on the tracing.

The patient is completely flaccid and unresponsive to painful stimulation, but as the paramedics debate the initiation of chest compressions, she spontaneously begins to recover. Her asystolic rhythm changes back to a normal sinus rhythm at a rate of 86 just as suddenly as it stopped.

The patient awakes a few seconds later with no recollection of the event, which lasted approximately 30 seconds.

Subsequent reevaluation of the patient after the syncope reveals no new abnormalities. Her vital signs return to normal and she denies any complaint. Since the patient is asymptomatic, no further treatment is indicated, but the transport is upgraded to emergent and the destination hospital is changed from the local community ED to the larger hospital downtown with expanded cardiac capabilities.

The patient experiences three more episodes of asystole during transport, which each resolves spontaneously in the same manner as the first. She also experiences a sinus arrest lasting approximately 20–30 seconds with subsequent loss of consciousness followed by spontaneous resolution back into a sinus rhythm accompanied by strong vital signs.

In the ED
The patient arrives at the ED conscious, alert and complaining of no symptoms. Due to her presentation, she’s placed in an available bed where the physician performs an evaluation and workup, including an ECG, lab work and a cardiology consult.

The patient suffers three more attacks while in the ED and is eventually admitted to the ICU on a dopamine drip in order to support her heart rate. She has an internal pacemaker implanted that evening and is discharged in good condition a few days later with a diagnosis of Stokes-Adams syndrome with an underlying sinus nodal deficiency.

Discussion
A syncopal episode, or “syncope,” is a transient and complete loss of consciousness and postural muscle tone caused by temporary hypoperfusion of the brain. Syncope can be caused by many underlying triggers, but the defining characteristic of the condition is that it spontaneously resolves without need for intervention and leaves no long-term effects. It’s commonly referred to as “fainting” and is a common complaint of persons requesting an EMS response.

Although many causes of syncope are benign, others carry significant risks for morbidity and mortality, and it’s important for caregivers not to discount any possible causes.

A thorough history and physical exam must be performed in order to zero in on the underlying cause. EMS providers have a unique opportunity to influence the care of patients suffering from syncope because they’re usually the providers summoned to the patient’s side when the condition is most acute. Therefore, EMS providers have the opportunity to observe the patient’s initial presentation as well as the environmental and other situational factors around the patient during their episode. This information can prove invaluable to the patient’s ultimate diagnosis and definitive care.1

Although syncope can be caused by many underlying conditions, in this case it was cardiac in origin, which highlights the importance of initiating ECG monitoring early in the patient’s care. This can help catch any arrhythmogenic causes of the event, which can help cardiologists identify and definitively treat the patient’s underlying arrhythmia.2 This patient was ultimately diagnosed as suffering from Stokes-Adams syndrome—a condition where the heart’s sinus node is transiently blocked, causing long sinus pauses and periods of asystole.

Persons suffering from Stokes-Adams syndrome will have Stokes-Adams attacks similar to the case described above where an ECG monitor will show asystole or even v fib for periods of up to 30 seconds. Since the sinoatrial node block is transient with Stokes-Adams, the arrhythmia usually terminates on its own and a normal sinus rhythm is restored.

Patients with Stokes-Adams syndrome almost always require the implantation of a pacemaker and, once treated, have excellent prognoses. However, if untreated, the one-year mortality for Stokes-Adams syndrome can be quite high.2

While the term “Stokes-Adams attack” is falling out of favor as more underlying pathologies are identified, classical Stokes-Adams attacks exist and can be identified by their presentation on an ECG. Occasionally, a 12-lead ECG will show a bizarre “giant T-wave inversion” that’s poorly explained.

Although definitive treatment for Stokes-Adams syndrome and syncope caused by other forms of sinus nodal dysfunction and sick sinus syndrome is an implanted pacemaker, temporizing treatments include transcutaneous external pacing using an external pacemaker set to a demand mode, as well as pharmacological intervention for rate support. Usually, however, the attacks are self-limiting and don’t require field treatment unless symptoms don’t resolve on their own.

Conclusion
Carefully evaluate and continuously monitor all patients who’ve experienced syncope in the field. The information gathered and treatments provided by all levels of EMS providers can have a profound impact upon these patients’ ultimate recovery.

References
1. Lemonick DM. Evaluation of syncope in the emergency department. Am J Clin Med. 2010;7(1):11–19.
2. Gauer RL. Evaluation of syncope. Am Fam Physician. 2011;84(6):640–650.

Resources

  • Baumrind D. (Aug. 6, 2011.) 89 year-old female CC: “Sick.” EMS 12-lead. Retrieved July 15, 2011, from www.
  • ems12leadcom/2011/08/06/89-year-old-female-cc-sick/.
  • GP Notebook. (n.d.) Stokes-Adams attack. Retrieved July 15, 2014, from www.gpnotebook.co.uk/simplepage.cfm?ID=1241907203.
  • Harbison J, Newton JL, Seifer C, et al. Stokes Adams attacks and cardiovascular syncope. Lancet. 2002; 359(9301):158–160.