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Lost consciousness on the job… November 26, 2012

Posted by Andy Jagoda, MD in : Cardiovascular , trackback

A 49-year-old male construction worker presents to the ED reporting a brief loss of consciousness 30 minutes prior to arrival while climbing through a crawlspace at work. He reports a prodrome of feeling short of breath, lightheaded, and dizzy, with associated midsternal chest pain. Family members at the bedside report that he was complaining of generalized weakness with mild shortness of breath at rest and on exertion for the past 3 to 4 days. His past medical history is significant for rectal cancer treated with resection, a traumatic fracture of L3, and deep vein thrombosis 9 months ago, after which he completed a 6-month course of warfarin. The patient denies use of tobacco, alcohol consumption, or use of illicit drugs. There is no family history of any medical problems. His vital signs upon arrival are: temperature, 36C; blood pressure, 104/79 mm Hg; heart rate, 106 beats per minute; respiratory rate, 20 breaths per minute; and oxygen saturation, 95% on room air. He is in no distress, is sitting upright on the stretcher, and is speaking in full sentences. Aside from a regular tachycardia, his exam is normal. Initial ECG shows a sinus tachycardia at 106 beats per minute, rightward axis deviation, ST-segment depressions throughout, and deep T-wave inversions in the anterolateral leads. Laboratory analysis, including cardiac markers, electrolytes, CBC, and renal function are remarkable only for a platelet count of 115,000 x 109/L. Initial cardiac markers and electrolytes are normal. You put acute coronary syndromes on the top of your differential and admit the patient to the observation unit, but you wonder if there is anything else that should be done while waiting for the second troponin…

What do you do next?

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Comments»

1. manoj kr sarma - December 1, 2012

D Dimer,bedside ECHO for RARV dilatation to rule out PE.

2. Ahmed alani - December 1, 2012

Echo cardiography to r/o Hocm
Ct angio to r/o PE
ECG holter to r/o arrhythmia ,AF,Chb
EEG toR/o epilepsy
Ct brain to R/o Cva

3. Mostafa - December 1, 2012

According to his PMH and presenting complaint, TLOC in this case might be due to pulmonary emboli. So bedside echo, or Doppler sono can be helpful to rule out PE.

4. Shelby ClayRogers - December 1, 2012

CT his chest with a PE study to evaluate for a recurrent PE as the cause of his symptoms…

5. R Sorensen - December 1, 2012

D Dimer, CT Angio Chest

6. Athanasios Pantelis - December 1, 2012

According to his PMH (colorectal Ca, surgery, spinal cord injury, previous event of VTE) and the clinical exam (SOB, tachypnea, tachycardia, chest pain, mild desaturation), this patient is at high risk of pulmonary embolism (approx. 40%, according to Wells’s criteria). He deserves at least a triple-rule-out CT scan and a D-dimer test at least, in order to assess for this very entity, as well as other pathology from the chest (such as subacute aortic dissection or intramural hematoma, which would specifically justify the relative myocardial ischemia depicted by T-wave inversion).

7. Jeannette - December 1, 2012

PE!!! I will do CT Scan chest angio

8. Gerald Brody - December 1, 2012

Carboxyhemoglobin

9. Bikedoc111 - December 1, 2012

Lovenox, d-dimer, CT Chest

10. Camilo Benavides. - December 1, 2012

in this case I would like to ask for a AngioTAC of lung vessels and an echocardiogrham, he has a intermediate probability for pulmonary embolism. He is not in inestability, so we can start antiisquemic, antiagregant, and anticoagulant management for coronay acute syndrome, that serve as for CAS as PE. We do not asf for d dimer, because it will be elevated in the context of CAS.

11. Justin Adkins - December 1, 2012

His vital signs are stable. I have high pre-test probability of PE. I would obtain CTA chest to rule out PE.

12. STEFANO FRANCHINI - December 1, 2012

contrast enhanced chest ct scan (ct angiography)

13. Namis - December 1, 2012

pulmonary embolism

14. iram shakir kiani - December 1, 2012

spiral ct chest to rule out pulmonary embolism…would not do a d dimer as he is a hi risk in veiw of his rectal ca even if operated

15. Jess - December 1, 2012

Saddle Pulmonary embolism

16. Jess - December 1, 2012

Ekg findings and elevated trop can be seen with Pulmonary embolism. thrombocytopenia may indicate consumption by large clot. Concern for Saddle pulmonary embolism given syncope and hypotension

17. Synapstic - December 1, 2012

I’d be extremely concerned about a PE in this fellow in addition to MI, CO poisoning etc. But with the history of Ca, DVT, tachycardia and heart strain on EKG, I would jump right to Chest CT without waiting for a ddimer.

18. juliana karp - December 1, 2012

The patient likely has a PE. Recommend spiral CT next, or, if any leg swelling ultrasound can be done and if positive empiric treatment for PE

19. fmad - December 1, 2012

ct angiogram

20. Parrish Eilers - December 1, 2012

CT of the chest with contrast, to R/O a PE.

21. Michael Lam - December 1, 2012

How about a CT angio to rule out PE.

22. Jim Squires - December 1, 2012

CT ANGIOGRAM to r/o pulm embolism

23. Jon Cheah - December 1, 2012

This man needs an urgent CT pulmonary angiogram to exclude a pulmonary embolus. His chest radiograph may already show signs of right heart strain ie right heart enlargement .

With a past history of a treated cancer, previousSaad said his daughter later told him that nothing had happened as she had spent the day with Mohd Fahmi before he sent her over to a relative’s house.

DVT and signs suggestive of hypoxia ie Sats of 95% and RR of 20 suggest a pulmonary a etiology for his syncope.

24. Brandon - December 2, 2012

CTA

25. Brandon - December 2, 2012

and start heparin

26. Dr. Brown - December 2, 2012

Patient is noted with shortness of breath on exertion and generalized weakness 3-4 days. Also noted is lose of consciousness in a crawl space at work. There could be several causes for his symptoms, such as pulmonary illness, arrhythmia, decreased oxygen in the crawl space, endocrine illness and cardiac illness.
Additional studies to order are chest x-ray, ECHO, blood gas, glucose, CO2 level and obtain additional history. Additional information needed is all medicines being taken including non-prescribed, allergies, prior surgeries, prior medical diagnosis and review of systems. Results of tests and additional history will lead to additional evaluations as indicated, such as pharmacological stress test, cardiac cath and consultation as indicated.

27. Andreas Huefner - December 2, 2012

My next steps while waiting for the Troponin would be a Chest X-Ray (widened mediastinum – aortic dissection?), an echocardiogram and D-Dimer (PE?). If any of these tests were positive I would proceed with Angio-CT of the chest.

28. Bijaya Ghimire - December 2, 2012

rule out pulmonary embolism via CT chest PE protocol.

29. KSGates - December 2, 2012

CTA Chest PE protocol

30. Dr Myrna Saraiya - December 2, 2012

CT angiogram or VQ scan
This person maybe having another PE.

31. Roland Bingisser - December 3, 2012

Pulmonary embolism should be considered due to History and intermediate to High preitest probability, Where d Dimers can be omitted. Anticoagulation should be started.
Ps: if ultrahigh sens. Trop. Was Usedom, the exclusion of MI is 92% in a First normal trop!

32. Janardan Tallam - December 3, 2012

Patient needs to be checked for any exposure to any chemicals and check carbon monoxide levels.

33. Jonathan Cheah - December 5, 2012

This man needs an urgent CT pulmonary angiogram to exclude a pulmonary embolus. His chest radiograph may already show signs of right heart strain ie right heart enlargement .

With a past history of a treated cancer, DVT and signs suggestive of hypoxia ie Sats of 95% and RR of 20 suggest a pulmonary a etiology for his syncope.

ECG changes : sinus tachycardia at 106 beats per minute, rightward axis deviation, ST-segment depressions throughout, and deep T-wave inversions in the anterolateral leads.

the sinus tachy/RAD and deep TwI in anterolateral also brings PE is the first differential.

apologies could you re-edit my initial answer ? (accidentaly a news item appeared on my paste board — how embarassing)

34. Martha Karuga - December 5, 2012

Spiral CT chest to R/O PE.

35. mary - December 5, 2012

Tromboembolismo pulmonar

36. rita cohen - December 8, 2012

this patient had an episode of suncope .
past / recent history suggest a hypercoagulability state because of the ca of prostate .
the differential diagnosis for the syncope , taking in consideration the sinus tachycardia and the EKG chages that I would have thought of are –
1- an episode of PE manifested by syncope
2- pericarditis ( because of the malignancy entering the lymphnodes?) – cuasing cardiac arrythmia that caused the syncope
3- metastasis to the brain from the prostate – cuasing seizure and syncope
4- ACS

my next stepts would have been , start anticoagulation and proceed with –
1- bedside heart echo ( will give me information about – pericarditis , starin on the rt side from PE or signs of ACS )
2- CT protocol PE/DVT
3- CT of brain and consult a neurologist ( considering EEG)
thank you ,

37. uttambhatta - December 9, 2012

though late but CT pulmonary angiogram to r/o PE would be the initial and d dimer to r/o PE also.
CxR can b initial backup either
repeat ECG for any changes

All comments are held for approval.



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