Interesting Case

82 year old man Brought in to RAZ by EMS 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 BP 121/71 HR 76 HR 76 RR 18 RR 18 O2 95% on 2 liters O2 95% on 2 liters T 36.7 T 36.7

Patient awake Confused Not oriented to place or time Doesn’t remember what happened

Fortunately… His wife is there His wife is there

Unfortunately… She’s almost as confused as he is She’s almost as confused as he is She can tell you what happened, though She can tell you what happened, though

History Shopping – fell backwards while walking. Shopping – fell backwards while walking. No prodrome No prodrome Hit back of head on floor Hit back of head on floor

Past Medical History Two recent falls in the past month – wasn’t seen in hospital for these Two recent falls in the past month – wasn’t seen in hospital for these Dementia Dementia Rarely sees a doctor Rarely sees a doctor No medications No medications

On exam T 36.7 HR 76 RR 18 BP 121/71 O2 95% on 2 liters T 36.7 HR 76 RR 18 BP 121/71 O2 95% on 2 liters CN exam normal CN exam normal Hematoma right occiput Hematoma right occiput HR regular, no murmur HR regular, no murmur Wife thinks slightly more confused than usual Wife thinks slightly more confused than usual

What next? What next? Any concerns? Any concerns? Differential Dx? Differential Dx?

Time to move Time to move Needs a monitored bed Needs a monitored bed

Investigations? Investigations?

Investigations CBC, Lytes, Creatinine, Glucose, Mg, Phosphate, Calcium, Troponin CBC, Lytes, Creatinine, Glucose, Mg, Phosphate, Calcium, Troponin ECG ECG CT head and C-spine CT head and C-spine

ECG RBBB RBBB Left Anterior Fascicular Block Left Anterior Fascicular Block

CT CT C-spine normal CT C-spine normal Cleared C-spine precautions Cleared C-spine precautions

CT head

CT Head Report Intraparenchymal hemorrhage involving bilateral posterior parietal lobes at occipital junction Intraparenchymal hemorrhage involving bilateral posterior parietal lobes at occipital junction Small SAH right frontal lobe Small SAH right frontal lobe No midline shift No midline shift

Meanwhile… Patient ticking along happily until… Patient ticking along happily until…

I hear some commotion… Patient is slumped over and the monitor shows this rhythm Patient is slumped over and the monitor shows this rhythm

Asystole! Asystole! ! ! !

Spontaneous Resolution Spontaneous Resolution Get the crash cart Get the crash cart Pads put on Pads put on

Quickly now… Let’s have a talk about Level of Care Let’s have a talk about Level of Care Full bore ahead Full bore ahead

Who ya gonna call? A. Ghostbusters A. Ghostbusters B. Your Mom B. Your Mom C. The laundromat (underwear feels sort of damp) C. The laundromat (underwear feels sort of damp) Cardiology Cardiology

Next step Transvenous Pacer Transvenous Pacer Patient agitated – required some sedation, but procedure otherwise successful Patient agitated – required some sedation, but procedure otherwise successful

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

Syncope 1-3% of all ED visits 1-3% of all ED visits 1-6% Admissions 1-6% Admissions

Causes Vasovagal, Carotid sinus syndrome Vasovagal, Carotid sinus syndrome Neurologic – SAH, Subclavian steal Neurologic – SAH, Subclavian steal Medications Medications Orthostatic hypotension Orthostatic hypotension Pulmonary Embolus Pulmonary Embolus Cardiac Cardiac

Cardiac Syncope 1. Structural – Aortic Stenosis, Cardiomyopathy, MI 1. Structural – Aortic Stenosis, Cardiomyopathy, MI 2. Dysrhythmias – Brady and Tachy 2. Dysrhythmias – Brady and Tachy

Bradysrhythmias 2 nd or 3 rd degree heart block 2 nd or 3 rd degree heart block Sinus node disease Sinus node disease Pacemaker malfunction Pacemaker malfunction

Tachydysrhythmias Ventricular tachycardia SVT A Fib A Flutter

San Francisco Syncope Rules CHESS CHESS C – History of CHF C – History of CHF H – Hematocrit < 30% H – Hematocrit < 30% E – Abnormal ECG E – Abnormal ECG S – Shortness of Breath S – Shortness of Breath S – Systolic Blood Pressure < 90 S – Systolic Blood Pressure < 90

“Abnormal ECG” Dysrhythmias Dysrhythmias WPW WPW Brugada Brugada Prolonged QTc Prolonged QTc Any new abnormality Any new abnormality

Boston Syncope Rules Broad set of rules – 25 criteria Broad set of rules – 25 criteria Misses our patient Misses our patient

Short-Term Prognosis of Syncope (STePS) 4 Independent predictors – 4 Independent predictors – 1. Abnormal ECG 1. Abnormal ECG 2. Concomitant trauma 2. Concomitant trauma 3. Absence of prodrome 3. Absence of prodrome 4. Male gender 4. Male gender

Back to our patient Admitted to Cardiology Admitted to Cardiology Transferred to Foothills for permanent pacer Transferred to Foothills for permanent pacer Slow to recover from anaesthesia and transferred to ICU Slow to recover from anaesthesia and transferred to ICU

Tachyarrhythmias – started on a metoprolol Tachyarrhythmias – started on a metoprolol Stabilized somewhat – transferred to CCU at PLC Stabilized somewhat – transferred to CCU at PLC Diagnosis of Sick Sinus Syndrome Diagnosis of Sick Sinus Syndrome No interventions regarding the intraparenchymal bleeds No interventions regarding the intraparenchymal bleeds

One more thing Anchoring Anchoring Start with an anchor – something you know – and adjust in the direction you think is appropriate Start with an anchor – something you know – and adjust in the direction you think is appropriate Often not enough adjusting Often not enough adjusting