63 year old male CC: Syncope

EMS is called to the home of a 63 year old male who has experienced a syncopal episode.

On arrival the patient is found sitting in a dining room chair that his spouse brought to the foyer. A grocery bag is up-ended with groceries all over the floor.

The patient has vomited but he does not appear to be incontinent of urine.

He appears to be acutely ill.

The patient is awake and oriented to person, place, and time but not event.

Skin is cool, pale, and diaphoretic.

The patient’s baseline SpO2 is 96. He is placed on oxygen via NRB mask @ 15 LPM.

He denies chest discomfort, palpitations, or shortness of breath.

Past medical history is significant for hypertension and congestive heart failure.

Medications include aspirin, spironolactone, and carvedilol.

Vital signs are assessed.

  • RR: 20
  • HR: 64 R
  • BP: 102/58

The cardiac monitor is attached.

A 12-lead ECG is captured.

What’s next?

See also:

63 year old male CC: Syncope – Conclusion

30 Comments

  • Trevor Smith says:

    Keep the pt on O2 via NRB @15 lpm. Initiate large bore IV access and initiate rapid transport. Possible STEMI d/t ST elevation in V1, V2, and V3 with possible reciprocal change in aVF. Notify hospital enroute and provide supportive care.

  • Ryan says:

    Agreeing with trevor on the stemi, and initial treatments, I would be getting a 15 lead just to get a look at the other side if time permits. Otherwise, full compliment of ASA, and one shot of nitro as he is still in decent condition to see if I can change how v1, 2, 3 look.

  • Liam Sullivan says:

    Anterioseptal STEMI with contiguous elevation in V1, V2, V3, possibly V4, hyperacute T waves in V1-V3.

    NRB@15lpm, IV access, additional asa, STEMI alert and rapid transport to PCI center.

  • Christopher says:

    3L shows NSR @ 60-70. 12L shows LAE and STE V1-V2. Going to obtain posterior leads. BGL. ASA. Pt has no C/P complaint so I will be withholding NTG. Watch for changes on 12L, not entirely sure its an isolated septal MI but I’m still suspicious for one. Going to consider a bradyarrhythmia or tachyarrhythmia as the cause of the syncopal episode as well.

  • Trevor Smith says:

    My protocol is no NTG w/o CP and no ASA if taken in last 24 hours. Since he takes it daily probably neither would be administered. I agree with Ryan on the 15 lead or just V3R and V4R per my protocol.

  • BFT Medic says:

    Continue 02, Iv x2, STEMI ALERT, 15 LEAD.

  • Bill says:

    Is this guy going directly to the Cath-Lab or will they attempt to re-perfuse using thrombolytics? What about some Zofran? By 15 lead, do you mean a right sided look, e.g.: V4R? If so, I agree.

  • Ray Galante says:

    Thank you for the insight reading EKG Paramedics. One basic question that is not addressed in the assessment is the PT experiencing any PAIN?

  • Dave says:

    I would agree, treat symtoms, 02, consider ASA, no need to nitro yet, take a look at a 15 lead, meaning VR4, Code STEMI alert, and take to a appropriate hospital.

  • Lynn Howell says:

    Due to pt’s physical presentation along with STE in V1, V2 and V3 w/reciprocal changes, maintain 15 lpm O2 via NRB, initiate lrg bore IV access x 2, position of comfort and trend for changes every 5 mins or prn. Confirm that pt took ASA (confirm dosage of 324 mg) within last 12 hrs-if not, 324 mg ASA PO. If time permits, reverse 12 lead for evaluation and comparison due to pt’s hx of CHF. Small fluid bolus to increase pt’s volume, and monitor introduction of CP at any point. Call in STEMI alert, as pt appears to have a possible septal infarct that is progressing into anterior region. Rapid transport and continual re-evaluation.

  • Martyn UK says:

    Well its about time I joined the party and start to comment.

    I am still quite new to this so please if i’m barking up the wrong tree then do tell me!

    I see…

    Sinus rhythm of 63 with a frontal plane QRS axis of +15deg.
    Morphologically assessing the precordials I note poor R wave progression V2, V3, V4 with STE V1, V2, V3.
    Signs of LAE V1
    On the limb leads I see q waves in III and possibly aVF but with the axis being +15 I will ignore III as a cavity lead. Is the q wave pathological in aVF?..probably not)
    Can’t see any STE in the limb leads and unfortunately can’t determine T wave axis due to artifact.
    P wave in II borderline LAE.

    So my guess..

    Partial thickness injury/infarction in the anterior wall.

    Treatment:
    Check left arm connection and attempt to tidy up ecg trace.

    Our new guidelines indicate high flow oxygen only for spO2 level <94%.
    In this case i would go for a 60% O2 mask @ 4ltr.
    BP is concerning and with no chest discomfort I would hold off 2mg nitrate buccal.
    300mg Aspirin PO.

    To PCI or not PCI well our PCI lab doesnt receive 12 leads from the life pak anymore so very annoying. I would probably go our nearest A&E unit with this one and keep patient on the trolley whilst a doctor assess's.

    Cheers

    Martyn

  • John Renaud says:

    I definitely agree that there is a STEMI goin on here, however this guy has a serve hx of HTN, and his pressure is 102. I think I would also start thinking about getting some fluids on board. Probably not a whole lot, but I would at least titrate to see if that has any positive effects.

  • Isaiah says:

    This is interesting I am new EMT-B I will continue with a Non-rebreather and Notify ALS cause in my region usually a syncope call is a BLS/ALS call obtain a 12 lead strip as well as check his vitals every 15 min call a STEMI alert transport too a hospital paferably a medical center on the way too that hospital re-assess the patients vitals for any change in condition.

  • Ahura says:

    IV with a small fluid bolus to keep BP up, O2 at 15lpm via NRB, and continue to monitor the pt. Transmit the 12 lead EKG to the hospital and alert them of a possible STEMI. However since the pt is not having any pain and has taken ASA already, I would withhold drugs. However I would contact medical command to find out if a small dose of morphine is in order to dilate the vessels without effect on the BP.

  • Arlen says:

    I’ll go prepare the gurney…

    😉

  • Brian says:

    02 NRB 15 lpm 12 lead EKG IV with samll fluid bolus. ASA, with hold if they had already taken 325 mg in the last 24 hour. If they only took a baby ASA, I’d give them another 3 baby aspirin. Transmit the 12 lead to hospital call a STEMI alert. No nitro because he’s not complaining of CP.

  • Aharon says:

    from the story we know that that guy havent chest pain so I think that the reason for his syncope is any arrythmia so I give him a O2 , make a vein line maby give him a little fluid and chack a BP , and monitor and transport him hospital

  • Rick says:

    Check also to see if he is compliant with his meds: Did he D/C or skip then make up (double up) doses?

  • Scott says:

    Sinus @ ~ 64, no ectopy. LAE w/ ~ 2 mm STE in V1, V2 and ~ 1.5 STE in V3 w/ tall T’s in the same. There is T wave flattening in: I, avL, V5, and V6. I’m not sold on the Q wave in III. I’d like to get a better look at it.

    Tx: high flow O2, IV (w/ 2nd enroute), investigate his ASA regimen and consider more, 4 mg of zofran to prevent further vomiting, subsequent vagal stimulation, and prevent possible adverse side effects due to the ASA. I’m going to be keeping an eye on his QTc, looking for ectopy, keeping the combo-pads nearby, and doing serial 12’s. I don’t see a need for a look @ the R sided and posterior leads. It’s not going to effect my tx.

  • RM says:

    Is there a need for r sided leads in the absence of changes in inferior leads? I am of the impression there is not.

    Posterior leads showing reciprocal changes might make the diagnosis of stemi more likely but absence wouldn’t mean too much. I don’t see a need for these either?

  • Note the Q-waves and some slight elevation as stated above.

    Also I always say, a funky looking T makes me think there may be an extra P. Some of the T-wave downslopes are indicative of a hidden P-wave, right at the point that would fit. Just trying to consider an option not yet mentioned…

  • BJ says:

    I’ll help Arlen with the gurney 🙂

  • Snafu says:

    I have a couple of questions.

    ASA is the only intervention we have for this patient that demonstrably reduces mortality and morbidity. It has a very favourable risk/benefit profile. However it only acetalyses COX in platelets already in circulation, not the next 1x 10^12 or so that are produced in the 24 hours since his last dose. Given this, why would we withhold aspirin?

    Secondly, given that high FiO2 in AMI has no proven benefit, and indeed there is a reasonable evidence that there may be increased size of infarct from decreased coronary blood flow and increased activity of oxygen reactive species, why are we all giving this patient 15litres/min via non-rebreather?

  • arnel says:

    PT is a known hypertensive and CHF sec to 1. Now BP is low and had syncope. Neuro or cardio cause? From the ecg – SR in the 60’s, LAA, Q waves in 3/aVF, ST flattening in aVL, ST elevations V1-3, distortion of T waves in V1-6. Probable old inferior wall MI, consider RV infarct (isolated RV is not so common), consider 2:1 AV block vs TU fusion (distortion of T waves in precrodial leads). What to do? Do right chest leads, O2, ASA, NO NITRATES, prepare for progression to high grade AV block. Let the doctors do the verdict.

  • Hillis says:

    Very interesting and so curious to know the result of this case .
    Anyway i would firstly perform new better quality 12 leads or maybe if the patient’s condition permit perform 15 leads ECG and to see if more obvious ST changes occur. Honestly am not so much impressed about the STE in the anterior leads i think it’s more to be normal variation . The III lead looks wierd and is that q wave in aVF!! Does the patient had any symptoms the last 24hours or even more ?
    Am thinking about inferior STEMI even the clinical presentation of syncope is more common with inferior infarction, but of course it could be arrythmia or any other cause .
    That’s why firslty perform better quality ECG . Don’t forget always you are treating the patient not ECG so try to stabilize the patient give O2, maintain IV line and treat the patient’s symptoms .

  • Troy says:

    Good diagnoses to me guys. I agree with the V4R check for right side MI, but since you have a septoanterior STEMI you know it’s not isolated. My only recommendation is to use a 4×4 gauze and rub the patient’s skin where your leads are placed. Rubbing off the epithelial cells will sometimes clear up that artifact. 🙂

  • Mark C. says:

    Old (recovered) inferior. Get a clean ECG. Am I the only person thinking of benign early repolaristaion syndrome? Can’t prove this in-field so aspirin and fluid challenge for BP (assume clear chest). No GTN (pain free, and look at that BP). I will not be surprised if the findings at hospital are other than cardiac. Don’t get me wrong, I would treat this as potential cardiac, but it could be so many other things. In the absence of increasing height of st segments during management, I am just not so ‘excited’ by them.

  • Nic N says:

    I beg to differ. Though I agree with the obvious STE noted, the underlying rhythm is AF with abberant conduction most likely through a slow right ventricle outflow tract.

  • Terry says:

    AFIB?? No way. Lets break it dowm. The rhythm is regular and there are pwaves before the qrs complexes. The qrs is wnl as is the pri. Ther rate is wnl. Axis is a little to the left but not bad. There is also a deep qwave in lead III. Probably from an old infarct. So now we know that the rhythm is a sinus rhtyhm lets look at the st elevation. STE in leads V1 V2 and V3=Septal wall MI. Just because a pt is pain free should NTG be witheld? No. Need to open up those coronary vessels. The pressure is a concern so I would give a fluid bolus. Here is a question though, if you know the pt is having an MI why all the extra leads? The important thing is to get a clear 12-lead and send it to the hospital. Especially if your thinking the pt is having an MI. Be careful about looking for zebras when the horse is staring you in the face.

  • Dusty says:

    I guess I’m a little confused why this pt needs O2 via NRB @15 lpm. I would venture to say he doesn’t need any O2 at all with a pulse ox in the mid 90’s and no report of respiratory compromise. In addition to the risks involved with O2 toxicity with a pt potentially having an MI. I would start with no O2. I don’t see the benefit of 15 lead at this point either. Having elevation in the anterior leads represents LAD occlusion. Why look elsewhere? Just throwing it out there.

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