Download Interesting Case

Interesting Case
82 year old man
• Brought in to RAZ by EMS
Presenting Complaint (nursing
notes)
“Ground level fall at 13:15
today. Unresponsive for 3
minutes after fall. No seizure,
but incontinent of urine.
Witnessed by wife.”
What do you want to know?
• BP 121/71
• HR 76
• RR 18
• O2 95% on 2 liters
• T 36.7
Patient awake
Confused
Not oriented to place or time
Doesn’t remember what happened
Fortunately…
• His wife is there
Unfortunately…
• She’s almost as confused as he is
• She can tell you what happened,
though
History
• Shopping – fell backwards while
walking.
• No prodrome
• Hit back of head on floor
Past Medical History
• Two recent falls in the past month
– wasn’t seen in hospital for these
• Dementia
• Rarely sees a doctor
• No medications
On exam
• T 36.7 HR 76 RR 18 BP 121/71 O2
95% on 2 liters
• CN exam normal
• Hematoma right occiput
• HR regular, no murmur
• Wife thinks slightly more confused
than usual
•What next?
•Any concerns?
•Differential Dx?
• Time to move
• Needs a monitored bed
• Investigations?
Investigations
• CBC, Lytes, Creatinine, Glucose, Mg,
Phosphate, Calcium, Troponin
• ECG
• CT head and C-spine
ECG
• RBBB
• Left Anterior Fascicular Block
CT
• CT C-spine normal
• Cleared C-spine precautions
CT head
CT Head Report
• Intraparenchymal hemorrhage
involving bilateral posterior
parietal lobes at occipital junction
• Small SAH right frontal lobe
• No midline shift
Meanwhile…
• Patient ticking along happily
until…
I hear some commotion…
• Patient is slumped over and the
monitor shows this rhythm
• Asystole!
•!
•!
•!
• Spontaneous Resolution
• Get the crash cart
• Pads put on
Quickly now…
• Let’s have a talk about Level of
Care
• Full bore ahead
Who ya gonna call?
• A. Ghostbusters
• B. Your Mom
• C. The laundromat (underwear
feels sort of damp)
• Cardiology
Next step
• Transvenous Pacer
• Patient agitated – required some
sedation, but procedure otherwise
successful
Syncope
• “Sudden transient loss of
consciousness associated with
inability to maintain postural
tone.”
Syncope
• 1-3% of all ED visits
• 1-6% Admissions
Causes
• Vasovagal, Carotid sinus syndrome
• Neurologic – SAH, Subclavian steal
• Medications
• Orthostatic hypotension
• Pulmonary Embolus
• Cardiac
Cardiac Syncope
• 1. Structural – Aortic Stenosis,
Cardiomyopathy, MI
• 2. Dysrhythmias – Brady and
Tachy
Bradysrhythmias
• 2nd or 3rd degree heart block
• Sinus node disease
• Pacemaker malfunction
Tachydysrhythmias
Ventricular tachycardia
SVT
A Fib
A Flutter
San Francisco Syncope Rules
• CHESS
• C – History of CHF
• H – Hematocrit < 30%
• E – Abnormal ECG
• S – Shortness of Breath
• S – Systolic Blood Pressure < 90
“Abnormal ECG”
• Dysrhythmias
• WPW
• Brugada
• Prolonged QTc
• Any new abnormality
Boston Syncope Rules
• Broad set of rules – 25 criteria
• Misses our patient
Short-Term Prognosis of Syncope
(STePS)
• 4 Independent predictors –
• 1. Abnormal ECG
• 2. Concomitant trauma
• 3. Absence of prodrome
• 4. Male gender
Back to our patient
• Admitted to Cardiology
• Transferred to Foothills for
permanent pacer
• Slow to recover from anaesthesia
and transferred to ICU
• Tachyarrhythmias – started on a
metoprolol
• Stabilized somewhat – transferred to
CCU at PLC
• Diagnosis of Sick Sinus Syndrome
• No interventions regarding the
intraparenchymal bleeds
One more thing
• Anchoring
• Start with an anchor – something
you know – and adjust in the
direction you think is appropriate
• Often not enough adjusting