17 year old male CC: Syncope

EMS is called to a local restaurant on a very hot day for a 17 year old male patient who experienced a syncopal episode.

On arrival the patient meets the ambulance in the parking lot and says, "Hey, man, I'm really sorry. We don't need the ambulance." 

Paramedics asks what happened and he says, "I just sort of… you know… took a hard swallow of Mellow Yellow… I guess…. and…. like…. I don't know if it went down wrong…. or whatever…. but like…. I sort of passed out…. but it's cool now."

The paramedics confirm that the patient is only 17 years old and inquire as to whether or not a parent or guardian is present. The patient's mother steps up and paramedics persuade her to allow them to "check her son out" in the back of the ambulance to "make sure everything is okay" on the condition that they don't receive a bill.

The patient also consents.

In the back of the ambulance the patient states that he is perfectly healthy. The only medical history is acne for which he takes a prescription medication but he forgets the name.

He appears well. The skin is pink, warm and dry.

He states that he has been drinking lots of fluids and making lots of urine.

(In response to one of the comments: he was specifically asked about his fluid status because the weather was hot and humid and EMS had been responding to many heat-related emergencies. This was not intended to convey in any way that the patient is an undiagnosed diabetic).

Both the patient and the mother deny any family history of syncope, seizures, or unexplained sudden deaths.

Vital signs are assessed.

  • RR: 16
  • Pulse: 90
  • BP: 127/84
  • SpO2: 100 on RA

Breath sounds clear bilaterally.

Neuro exam normal.

(Update: The BLG was 108.)

The cardiac monitor is attached.

A 12-lead ECG is captured.

The patient says, "So, am I going to live?"

What are your thoughts?

See also:

17 year old male CC: Syncope – Discussion

53 Comments

  • danny says:

    I say he’s either under the effects of a stimulant (mellow yellow, red bull, similar) OR he had a vaso-vagal episode 2ry to the blast of ice cold Mellow Yellow stimulating his unusually superficial vagus nerve.

  • Tina says:

    thinking this young man had a vasovagal response, since he mentioned that he took a hard swallow mellow yellow and passed out.

  • Eff Dogg says:

    when posed as a test question: I would respond with concerns about his borderline QTC, partially exascerbated by his erythromycin (the most common rx abx used for acne that can cause prolonged qtc syndrome). The increased urine output could suggest hyponatremia. This combined with his mild, understandable, tachycardia, could cause an R on T etc….
    when faced with this in real life: 12 lead, you're fine, follow up with your MD tommorow, sign here. I suspect I am not alone.
    The real crux of the issue is which scenario are we using here. The test question (where by virtue of it being a test question, something is wrong with the boy) or the real life scenario?
    F.

  • nunya says:

    Probably vagal episode, LVH on the 12 lead, recommend medical attention, if no sign here

  • saraswathi thangavel says:

    could be some arrythmias 24 hrs holter monitoring is needed and electrolites esp creatinine and  k to be checked.. 
    dd acute AWMI. to be confirmed  by ECHO or trop t /cpk MB and repeat ecg after an hour
    OTHER DD: HOCM

  • Jordan says:

    I'm interested in the polydispsia and polyuria, and given the history of acne it would wrap things up neatly if this patient turned out to be diabetic.  Given his age, then a thing not to miss would be DKA as a presentation of type I DM.
    The ECG could well be normal, and he could well have sinus tachy from a lot of caffeine and polyuria from a result of drinking too many caffeinated drinks.  On the other hand, the ECG could be showing the beginnings of hyperkalaemic changes.  Any chance of a random blood glucose?

  • HillbillyEMT says:

    Vagal response.  No problem.  Obviously a drinking problem.

  • Harrison says:

    Normal axis, normal intervals (well, qtc of 0.446 is normal enough). Normal PQRS. Hyperactue T in V1,V2 but no suspicion of AMI. Probably a normal finding for this kid. No ectopy. Sinus rhythm at 108.
    +1 for vasovagal
    This is a normal ekg.

  • Harrison says:

    4 lead shows sinus arrhythmia and is a poor tracing

  • casey says:

    hoofbeats of horses…
    could be vasovagal, otherwise s-tach and have a nice day.

  • Troy says:

    I see some delta waves!

  • nunya says:

    I get the polyuria/dypsia but it says it was a hot day. I noticed possible delta waves too, along with a borderline long qtc could be wpw but wouldn’t really concern me with this call.

  • Medic1078 says:

    Does he need to go to the hospital?  "Well, sir, if it was concerning enough that you called us, you should probably be evaluated by a physician."  Does he have an acute issue going on?  Likely not.
     
    I disagree that the 12 lead is even remotely suggestive of LVH, given the pt's demographic.  The high amplitude is likely a result of low impedence in a thin, healthy 17 y/o.  Polyuria in the setting of a new onset of diabetes is usually accompanied by a complaint of unrelenting thirst.  This was not mentioned.  Given the BG and the note added later in the scenario, I don't see this as a concern.  The possibility of a transient episode of an unspecified dysrythmmia cannot be ruled out, and for this reason the pt should be seen in the ED.  I also see the delta waves in there.  However, I'm still going with a vagal episode because most that end up in a tachy dysrhythmmia as a result of WPW do not spontaneously convert back to sinus.
     
     

  • D. Matt Wallace says:

    Too much caffeine.

  • ??? says:

    It looks like a bunch of dx in search of a medical emergency. Stop playing PCP and go do some pending e calls. The new medic curriculum is clearly a failure.

  • solanomedic762 says:

    Hyper K?

  • Obyrne4 says:

    The above statement of possible R on T isn't a strong possibility for anyone with a QT interval less than 600ms. It isn’t the prettiest 12 lead, and I would make sure that V4 is actually on the PMI and that the pericardial leads are not touching. Vasovagal is the most plausible option due to the heat. Also Mellow Yellow has roughly 53mg of caffeine per 12 oz. He’s going to be tachy for a while.  Another option in way way way left field is Reflex Sympathetic Dystrophy (RSD) which would be cool to see if reproduced but generally doesn’t occur in his age range.

  • 702 says:

    I agree with ???, why is everyone in search of a "problem?" There are way too many paramedics out there these days trying to play physician.

  • I want to sound smart says:

    Deleted due to incivility. Tom B.

  • TMoney says:

    @ I want to sound smart…100% agree 🙂
    Offer transport if they really want to go (sounds like they don't)…recommend discussion with regular family MD about the syncope and let them pursue it from there.  Encourage continued water (not soda) intake for the hot weather. 
    The scenario didn't speak much to a neuro exam.  Maybe check pupils, gait, speech, ask about headache etc etc.  No postictal period or actual seizure activity described so…again offer transport if requested or recommend follow up with the family MD.

  • probie says:

    To those saying he's outside the demographic for LVH, you probably should read up on HOCM — the leading cause of death in young athletes.

  • Nathan says:

    V3 has an abnormality no?  
    Real life?  If we're at level 0 (no units left to cover the city)  when the subject on scene who didnt call us and has no current complaint CAOx3 says I dont need you.   Im out!  Now, he's a minor so thats a little different. 
    Possibilities Im thinking:  WPW, Vagal (he choked on the drink?)     Whatever the cause its most likely cardiac (besides the fact that this IS the 12 lead blog:)  I would want to find out the name of any PO meds he's taking and do a quick lil' search on my epocrates app for side effects.
    Otherwise have a nice day! Mom sign here, Managment of reasturant sign witness.  Call us back if anything changes or you change your mind.

  • Nathan says:

    Re:hypertrophy
    I agree, Looks like there is evidence of hypertrophy.

  • Rsqumedic says:

    Eh…he is dehydrated and probably tachycardiac from the caffeine, as well as mildly hypovolemic. The kid is otherwise asymptomatic on exam and has no current chief complaint and no PMH mentioned that would lead anyone down the cardiac abyss. I would recommend that if mom is concerned to call the pt's pediatrician and follow up there. Of course, I would offer transport if requested, but I don't see any reason to immediately transport this kid by ALS to the ED and saddle the family with an unneccesary bill. If there was more to the story, ie: heavy exercise or exertional activity coupled with sudden syncope, then it might be wise to poke a little further. Absent a PMH of similar events, known cardiac HX, SZ, Neuro HX, or related information, why take him in? It is also possible this ECG is normal for THIS kid, and the syncope was related to dehydration or a vaso-vagal event……

  • Jim says:

    "well bud there is nothing showing me anything life threatening at this point.  but you did admit to passing out . and since i am not a doctor ,and i am unable to do blood work and the rest of the neat tests they have at the hospital out here , my professional opinion is that you go to the ED to be checked out.. if you want to come with us cool if not you could have your mom drive ya in . i would strongly suggest you don't get behind the wheel till  a doctor sees you. But if you don't want any medical attention , i will have a few more things to talk to you and mom about if that is the case and i will also have to give my medical command doctor a call . they may or may not want to talk to ya. after that i just need you mother to sign this refusal of services sheet" .
    ( then go into refusal mode if they choose that route or ride em in other wise)

  • Nick Adams says:

    I'm no doctor neither…….just a dumb paramedic……and yes, sometimes I drive too which makes me an ambulance driver too 🙂
    I'm really not concerned with the pt's QTI, delta waves (though I've been wrong about this before), whether or not the pt vagaled from drinking soda, or the pt is dehydrated.
    What I am concerned with, is the fact that a 17 y/o boy had a syncopal episode with no reasonable explanation….Syncope is not normal.
    Why this teen has LVH.  V2 + V5 = 44ish……and also, why he has a DBP of 84?  I know this is not so high, but if this kid is so healthy, why is it not in the 60's.
    I'm going with undiagnosed HOCM with a serious risk of SCD.  The next episode could be for good.  I would talk with the mother and get her to let us transport him based on the facts that I've found.  Transmit the 12-lead to the ED and let the ED physician speak with the mother.  Either way, the kid is going to the ED at that's it……lol

  • Kelly says:

    An interesting case and certainly a common chief complaint during extreme heat conditions. My first thoughts are vaso-vagal response due to swallowing cold fluids and sinus tachycardia secondary to too much caffiene. I am hesitant to say he is experiencing polydipsia or polyuria, especially with a normal BGL. I do agree he probably needs further work up, but if they refuse transport I would recommend fluids without caffiene such as water and provide them with a copy of the ECG and vital signs to take to whomever they follow up with. And of  course document, document, document.

  • Mursing Medic says:

    Hypertrophy? He's 17 folks. Teenagers, especially males can have increased voltage without it being LVH.
    He does have some peaked T waves in the precordials which would make me suspect dehydration (increased K possibly). Another clue is the "drinking lots of fluids and making lots of urine." While this in iteself may sound innocent due to the weather, and the story is that insipidus isn't being considered, a big flag is that he takes acne medication that he can't remember the name of.
    Accutane (if that's what he takes) is a highly potent, highly toxic medication that has some serious side effects. Some of which as listed on the NIH website are an "unusual thirst", "frequent urination", and "fainting"
    http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000532/
    I would think that a combination of the medication, it's toxic nature, and the weather would all contribute to a push towards eval at the hospital. That's when I would use the "I don't know about billing, but what I do know is that your son should be seen by a physician." line.

  • @ ??? and 702 says:

    If im not mistaken identyifing and attempting to correct or at least temporarily relieve the issues associated with the problem our patients are having is what we as Paramedics do,  im not sure how the two of you expect to do anything for your patients if you dont care enough to find out what the patients problem is.  Although we are not Dr.s and we do not technically diagnose pt.s in the field i think most medics would agree that we are fairly good so called medical detectives,  and I believe this is what both makes us able to treat our pt.s appropriately and gives us the confidence to do our job quickly and efficently.  Not to be an ass but i think both of your comments earlier were a little rediculous. 

  • Robert (Las Vegas) says:

    12 lead interpretation: Sinus Tachycardia, HLVV
    Person has upright p waves in lead I, II, II, & avf with inverted p wave in lead avr showing sinus in origin. Sinus tachycardia is based on a regular rhythm, p waves/qrs, and a heart rate > 100, but within the means of sinus tachycardia 220-(17)age = 203.
    High Left Ventricular Voltage (HLVV) is diagnosd on patient being less the 50 years of age, but still meeting the criteria for LVH which in this case is the sum of v2 & v5 being > 35mm. HLVV is a normal variant in young athletic males and is not of concern.
    Things to Rule Out: Hypertrophic Cardiomyopathy (HCM) would be ruled out since the patient does not have deep q waves in the precordial/lateral leads with the HLVV and Brugada Syndrome since it doesn't have the correct morphology in precordial leads v1-v3.
    I would be perfectly fine ama ing this person.
    Cheers,
    Robert

  • Andrew Moose says:

    "Have a nice day sir."  Tell them to follow up with their family physician due to the syncopal episode. Have them sign the refusal form and hopefully Im back before the stove burns the station down.

  • Jami says:

    This looks and sounds like WPW. Should be checked out! The few cases I have seen were very similar to this. Delta waves present. Syncope. Young. He can most likely plan on having an ablation.

  • David says:

    Based on his EKG and age group, I would suspect he has undiagnosed cardiomyopathy and had an episode of Vtach that put him of the ground.  He certainly should be evaluated further.

  • Eff Dogg says:

    re: there re way too many medics out there trying to play physician… more concerning- There are EVEN more out there NOT playing physician and insted playing taxi-driver. This blog is not for taxi-drivers
     F

  • tony says:

    based on the patients history,and the ekg;i would suspect a undiagnosed cardiac condition,and should be transported for further evaluation.better to air on the side of patient safety.
     

  • Mel The Medic says:

    Sinus arrythmia. More then likely a vagal episode from such a large gulp.  I would not really suspect anything regarding DKA, or even diabetes for at that.  Sugar is within normal limits especially after drinking something high in sugar.  Normally healthy teen, I would run labs to check his electrolytes.  Polyuria??  Hes drinking plenty of fluid as stated, which would make for good output, and caffeine increases the output of urine.

  • Paul Matera, MD, EMTP says:

    vitals are normal , except the pulse given does not match the ecg rate , there is some sinus arrhythmia on the strip, what we need to be concerned with is that it takes bilat cerebral insult to cause loc and he had loc, it is unlikely to be a circulating insult, ie hypoglycemia/drugs as these would still be apparent on arrival and return to awake state, generally syncope that suddenly occurs and suddenly resolves is cardiac/prefusion drop which leaves a combo of dehydration and dysrhythmia , QT not prolonged enough for an issue, +/- delta but no WPW at present, the history of taking a big swallow of a cold drink is interesting , if he was hot and a little dry and a little electrolyte deficiant then a hard cold swallow could stimulate the carotid body and cause brady and or as the bolus passes the heart via the esophagus could cause VF, this has been known to occur, the fact that he is fine now makes a scenario like this likely (plus that is what the history was) , as for should he go to the hospital YES unless his parents with full release agree and sign, EMS does not rule out , they rule in and treat if possible , it is much harder to prove a patient is perfectly healthy and safe than it is to treat their obvious injury, just my 2 cents, good case to think through

  • Christopher says:

    3- and 12-Leads look unremarkable for a 17yo M. History certainly suggests vasovagal episode, and given his vitals my suspicion for badness is very low. However, as Dr. Matera wisely points out, we should  consider the case where this was not such a simple event. We should let the parents know while we're an extension of the ED, we're not the ED itself. Explain the risks of refusing transport and provide a copy of the kid's ECGs if they choose to visit their PMD.

  • Bryan says:

    Robert, I think you made a good post, but I would argue that HCOM can never be ruled out by an ECG.  The best post on here is by Nick.  Syncope is not normal.  Could it be a benign?  Likely.  But that is nothing that anyone wants to diagnose in the field.  Cardiac origin is most likely here, including vagal/dehydration.  The drinking of a beverage could be a red herring, but it could be that the vagal stimulation slowed the AV conduction enough to allow an accessory pathway (WPW) to take over causing an SVT…syncope.  Or not.   This patient needs to be seen in the ED.  Explain the worst case scenario to the family, because if you work long enough, the worst case scenario will eventually be the result just by the law of averages.  Medics should always try and consider the possibilities, but don't let that keep you from getting the definitive care needed.  Paramedics can't dx properly in the field, not because of skill, but because of resources.  Not that a paramedic is usually wrong,they aren't, but all the possibilities can't be ruled out without more resources in many cases.   As far as HOCM, certainly something to consider in a young adult w/ cardiac symptoms, but I am unsure how in this case it would cause syncope.  Usually takes exertion to become symptomatic, but maybe dehydration/caffeine could cause this.  Something to think about.  My bet is still WPW, even though the PR is normal, the delta waves and the scenario fit, but I am probably wrong.  By the way, I am a paramedic and a 2nd year EM resident.  I would not feel comfortable sending this guy home with this presentation and ECG without at least speaking to a cardiologist.

  • Bryan says:

    Also, to those being critical of those who are pondering the possibilities, stop.  While you are correct that medics need to make should they practice within their scope( I think that was part of you point) thinking about the possibilities in each case makes the medic more prepared to act when things go North( I am southern and refuse to refer to bad things as going South,lol).  As I stated, don't waste too much time trying to dx when it is irrelevant to the pt care at the time, but this is a perfect scenario for thought discussion.  Does it matter on scene if this is HCOM,vs WPW vs dehydration?  Maybe not.   The pt will get fluid and should be on a cardiac monitor enroute.  But it is important to be aware of the possibilities, and if the pt crashes, it would be nice to have considered the possibilities before hand.  Critical thought it what makes the paramedic unique in the healthcare system.  Protocols are in place, but the EMTP must know which one is appropriate.  The full spectrum of EM from first responder to ED is like playing poker.  You must make decisions with limited information and someone down the road, with more information, will always be able to second guess you.  In this scenario, with an abnormal ECG, if this kid drops dead (unlikely), there is no way to defend not at least trying to convince the family to go to the ED.

  • ryan says:

    I see a sinus tach, otherwise normal. Dehydration is pathway number one. Transport by us or mom..don't care at this point. He probably should get a liter or two at the local ED with a followup with PMD.
    I'm fine with a release and mom taking him, heck, I'm fine with mom taking him home and feeding him water until he could drink his own urine because it's clear water. Caffine, plus hot/humid day, plus exertion. Gee…walks like a duck, but talks like a zebra? Not so much.
    It's a simple case of dehydration, with a sinus tach associated with it. We see a ton of artifact becuase he's thin, it's cold in our ambo box, and he's now probably shivering. Don't read into it. The big-tall T wave is probably an electrolyte imbalance.

  • Christopher says:

    One potential concern is overhydration and hyponatremia, especially if he's already making clear urine.

  • Paul Matera, MD, EMTP says:

    i reiterate my prior post at 10:29 am today , in a case where there is no apparent secondary gain to be unconscious i would warn again that although 85% of "syncope" goes un-diagnosed and and in the end was innocuous you will some day come across that zebra and being cavalier about the M+M of someone else is not what we are about in medicine, as far as AMAs in EMS … how about the darvon OD that was allowed to sign AMA on scene AFTER she was given narcan and then she got in her car drove 3 blocks and went LOC again and crashed into the back of the same medic unit that just released her AMA injuring her and both medics … explain that one to the mayor

  • 702 says:

    @ Bryan: Yes, that was partially my intent on that post. However, as someone else has stated before, "im not sure how the two of you expect to do anything for your patients if you dont care enough to find out what the patients problem is," we have found out what the problem is. We were given the HPI. My point is, even if we go far indepth with this exam, go through our Merck Manual, and find a diagnosis, we explain this to the patient and his mother and they still refuse our care, what does this change? Nothing. We can educate the mother, but I have found time after time, they say "He is fine now, I dont want the ambulance bill, I'll call the doctor." I am all about being prepared for the "curve-ball" patient's may throw us. But, sometimes, all the medical jargon in the world isn't going to change someone's mind. As far as them wanting transport, thats is great! We are not physicians (most of us anyway) and should not be acting like such. However, if this kid or his mother changed their mind, the treatment plan is to treat symptoms, establish ALS incase of change in patient condition, transport to an ED and give report. Moral of the story is, knowledge is great, but it can also be your enemy.

  • AW says:

    One of my favorite sayings:
    Knowledge is knowing a tomatoe is a fruit, Wisdom is not putting it in a fruit salad.
    We learn all kind os stuff that really has no place inside an ambulance call, but that's not to say we should not know it, or that we can't discuss it over coffee after the call, or on a blog such as this.
    I'm with those that said syncope is not normal and the boy needs to be seen in the ER.  I'd explain that I can't rule out everything and some things that are very serious first present as syncope.  Given the circumstances of heat and the unknown medication, most of that class a bad combination in heat and/or sun, plus the use of high caffine drinks I'd really want some bloodword done if he were my son, and I try and treat them all as family.
     

  • Pat says:

    "Mom, his 12-lead shows a couple of abnormalitites that could be consistent with electrolyte imbalance, but I don't believe he needs EMS transport. Call his doc and have a great day! Medic-7 clear."

  • Matt says:

    @Pat, do that 100 times on this patient and I'd be willing to bet at least once you'll see the inside of a courtroom or at least get to know an attorney. Dangerous attitude to take.

  • DW says:

    @ Pat.. He had a Syncopal episode… That in itsself is enough; or should be to encourage you or anyone else that the Child should ride via EMS to the ED.  Trying to get out of a call because he says he's fine, should  be the last thing on your mind.  Yes, it may be simple dehydration, and a slight electrolite imbalance, but that can only be properly diagnosed in a hospital setting. Dont worry about irritating the hospital staff because you brought in a 17 yr old with dehydration and ST.. Any sort of electrolyte imbalance could be cause for critical evaluation.  Remember it doesn't take alot of potassium to send someone into VFib and total cardiac arrest, and kids crash quicker and harder than adults.. Just something to think about before your sitting before your state panel explaining why you didn't do your job, and mom watched her son fall out on the way home, instead of the hospital.  If mo is a dr and says he's ok, then fine, the liability and the risk is on her, but we don't know that, and our job is to not take chances with other people's lives, its to make them better when we are called. 

  • darren says:

    Voltage criteria for LVH.
    ? Hypertrophic Cardiomyopathy?

  • Ngan Thanh says:

    I thinks about WPWs on ECG!

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