Case Conclusion — Brief Loss of Consciousness
April 6, 2014
Recap of April’s Case:It is a busy day in your ED when a 51-year-old woman arrives by EMS. She felt faint while riding her racing bicycle and got off just before losing consciousness. EMS found her conscious, but pale, with a heart rate, 50 beats/min; blood pressure, 90/50 mm Hg; respiratory rate, 25 breaths/min; and oxygen saturation, 98% on room air. She tells you that just before she got off her bike, she experienced pain in her throat, but she denies chest pain, shortness of breath, or headache. Her initial ECG shows a sinus bradycardia but is otherwise normal. She is an experienced marathon runner and has never had similar complaints. You wonder what could have caused the syncope and persistent bradycardia.
Case conclusion:? The 51-year-old bicyclist who was also a marathon runner did not have improvement of her SBP, which remained at 90 mm Hg. Furthermore, she had throat pain, which could have been an angina equivalent. Your primary concern was that she had a cardiac outflow problem because of an aortic dissection or a pulmonary embolism. A neurally mediated component to her syncopal event could not be excluded. A CT aortogram was ordered to assess for dissection. It showed a type A aortic dissection starting in the ascending aorta extending to just above her renal arteries. Her spinal cord arteries originated from the true lumen, explaining why she had no neurologic or other symptoms. The throat pain was attributed to radiating pain from the intimal tear in her ascending aorta. She developed pain between her shoulder blades later during her stay in the ED while awaiting surgical intervention. She made a full recovery after surgery.
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