Interesting CaseInteresting Case

82 year old man82 year old man

•Brought in to RAZ by EMSBrought in to RAZ by EMS

Presenting Complaint Presenting Complaint (nursing notes)(nursing notes)

““Ground level fall at 13:15 Ground level fall at 13:15 today. Unresponsive for 3 today. Unresponsive for 3 minutes after fall. No minutes after fall. No seizure, but incontinent of seizure, but incontinent of urine. Witnessed by wife.”urine. Witnessed by wife.”

What do you want to know?What do you want to know?

• BP 121/71BP 121/71

• HR 76HR 76

• RR 18RR 18

• O2 95% on 2 litersO2 95% on 2 liters

• T 36.7T 36.7

Patient awakePatient awake

ConfusedConfused

Not oriented to place or timeNot oriented to place or time

Doesn’t remember what Doesn’t remember what happenedhappened

Fortunately…Fortunately…

•His wife is thereHis wife is there

Unfortunately…Unfortunately…

•She’s almost as confused as She’s almost as confused as he ishe is

•She can tell you what She can tell you what happened, thoughhappened, though

HistoryHistory

•Shopping – fell backwards Shopping – fell backwards while walking.while walking.

•No prodromeNo prodrome

•Hit back of head on floorHit back of head on floor

Past Medical HistoryPast Medical History

•Two recent falls in the past Two recent falls in the past month – wasn’t seen in month – wasn’t seen in hospital for thesehospital for these

•DementiaDementia

•Rarely sees a doctorRarely sees a doctor

•No medicationsNo medications

On examOn exam

•T 36.7 HR 76 RR 18 BP 121/71 T 36.7 HR 76 RR 18 BP 121/71 O2 95% on 2 litersO2 95% on 2 liters

•CN exam normalCN exam normal•Hematoma right occiputHematoma right occiput•HR regular, no murmurHR regular, no murmur•Wife thinks slightly more Wife thinks slightly more

confused than usualconfused than usual

•What next?What next?

•Any concerns?Any concerns?

•Differential Dx?Differential Dx?

•Time to moveTime to move

•Needs a monitored bedNeeds a monitored bed

•Investigations?Investigations?

InvestigationsInvestigations

• CBC, Lytes, Creatinine, Glucose, Mg, CBC, Lytes, Creatinine, Glucose, Mg, Phosphate, Calcium, TroponinPhosphate, Calcium, Troponin

• ECGECG

• CT head and C-spineCT head and C-spine

ECGECG

•RBBBRBBB

•Left Anterior Fascicular BlockLeft Anterior Fascicular Block

CTCT

•CT C-spine normalCT C-spine normal

•Cleared C-spine precautionsCleared C-spine precautions

CT headCT head

CT Head ReportCT Head Report

•Intraparenchymal Intraparenchymal hemorrhage involving hemorrhage involving bilateral posterior parietal bilateral posterior parietal lobes at occipital junctionlobes at occipital junction

•Small SAH right frontal lobeSmall SAH right frontal lobe

•No midline shiftNo midline shift

Meanwhile…Meanwhile…

•Patient ticking along happily Patient ticking along happily until…until…

I hear some commotion…I hear some commotion…

•Patient is slumped over and Patient is slumped over and the monitor shows this the monitor shows this rhythmrhythm

http://upload.wikimedia.org/wikipedia/commons/9/9a/EKG_Asystole.jpg

•Asystole!Asystole!

•!!

•!!

•!!

•Spontaneous ResolutionSpontaneous Resolution

•Get the crash cartGet the crash cart

•Pads put onPads put on

Quickly now…Quickly now…

•Let’s have a talk about Level Let’s have a talk about Level of Careof Care

•Full bore aheadFull bore ahead

Who ya gonna call?Who ya gonna call?

•A. GhostbustersA. Ghostbusters

•B. Your MomB. Your Mom

•C. The laundromat C. The laundromat (underwear feels sort of (underwear feels sort of damp)damp)

•CardiologyCardiology

Next stepNext step

•Transvenous PacerTransvenous Pacer

•Patient agitated – required Patient agitated – required some sedation, but procedure some sedation, but procedure otherwise successfulotherwise successful

SyncopeSyncope

•““Sudden transient loss of Sudden transient loss of consciousness associated consciousness associated with inability to maintain with inability to maintain postural tone.”postural tone.”

SyncopeSyncope

•1-3% of all ED visits1-3% of all ED visits

•1-6% Admissions1-6% Admissions

CausesCauses

•Vasovagal, Carotid sinus syndromeVasovagal, Carotid sinus syndrome

•Neurologic – SAH, Subclavian stealNeurologic – SAH, Subclavian steal

•MedicationsMedications

•Orthostatic hypotensionOrthostatic hypotension

•Pulmonary EmbolusPulmonary Embolus

•CardiacCardiac

Cardiac SyncopeCardiac Syncope

•1. Structural – Aortic Stenosis, 1. Structural – Aortic Stenosis, Cardiomyopathy, MICardiomyopathy, MI

•2. Dysrhythmias – Brady and 2. Dysrhythmias – Brady and TachyTachy

BradysrhythmiasBradysrhythmias

•22ndnd or 3 or 3rdrd degree heart block degree heart block

•Sinus node diseaseSinus node disease

•Pacemaker malfunctionPacemaker malfunction

TachydysrhythmiasTachydysrhythmias

Ventricular tachycardiaVentricular tachycardia

SVTSVT

A FibA Fib

A FlutterA Flutter

San Francisco Syncope San Francisco Syncope RulesRules

•CHESSCHESS•C – History of CHFC – History of CHF•H – Hematocrit < 30%H – Hematocrit < 30%•E – Abnormal ECGE – Abnormal ECG•S – Shortness of BreathS – Shortness of Breath•S – Systolic Blood Pressure < 90S – Systolic Blood Pressure < 90

““Abnormal ECG”Abnormal ECG”

•DysrhythmiasDysrhythmias

•WPWWPW

•BrugadaBrugada

•Prolonged QTcProlonged QTc

•Any new abnormalityAny new abnormality

Boston Syncope RulesBoston Syncope Rules

•Broad set of rules – 25 criteriaBroad set of rules – 25 criteria

•Misses our patientMisses our patient

Short-Term Prognosis of Short-Term Prognosis of Syncope (STePS)Syncope (STePS)

•4 Independent predictors – 4 Independent predictors –

•1. Abnormal ECG1. Abnormal ECG

•2. Concomitant trauma2. Concomitant trauma

•3. Absence of prodrome3. Absence of prodrome

•4. Male gender4. Male gender

Back to our patientBack to our patient

•Admitted to CardiologyAdmitted to Cardiology

•Transferred to Foothills for Transferred to Foothills for permanent pacerpermanent pacer

•Slow to recover from Slow to recover from anaesthesia and transferred anaesthesia and transferred to ICUto ICU

•Tachyarrhythmias – started on a Tachyarrhythmias – started on a metoprololmetoprolol

•Stabilized somewhat – transferred Stabilized somewhat – transferred to CCU at PLCto CCU at PLC

•Diagnosis of Sick Sinus SyndromeDiagnosis of Sick Sinus Syndrome•No interventions regarding the No interventions regarding the

intraparenchymal bleedsintraparenchymal bleeds

One more thingOne more thing

•AnchoringAnchoring

•Start with an anchor – Start with an anchor – something you know – and something you know – and adjust in the direction you adjust in the direction you think is appropriatethink is appropriate

•Often not enough adjustingOften not enough adjusting