interesting case. 82 year old man brought in to raz by ems brought in to raz by ems
TRANSCRIPT
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
•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