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Brief Loss of Consciousness March 31, 2014

Posted by Andy Jagoda, MD in : Neurologic Emergencies , trackback

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. EMS provided 1 liter of normal saline without a change in her vital signs. In the ED, her BP is still 90/50 mm Hg. 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. She appears uncomfortable and complains of persisting throat pain and states she is afraid of dying. Her initial ECG shows a sinus bradycardia but is otherwise normal. Her past medical history is not significant. She takes no medications. She is an experienced marathon runner and has never had similar complaints. You wonder what could have caused the syncope and persistent bradycardia.

Share your diagnosis with us in the comments box below. The case conclusion will be published on April 7!

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Comments»

1. Kaleb A. Lane, MD - April 2, 2014

Patient may have experienced a right sided NSTEMI causing her to have throat pain, leading to the bradycardia, and a possible transient vfib/vtach arrhythmia that led to her loss of consciousness. Patient needs basic labs, cardiac enzymes, d-dimer and a CXR ordered. I would continue to IVF boluses to keep her BP elevated.

2. Robert Morlino - April 2, 2014

Vasovagal stimulation in the neck region. Need to check for anything protruding into this area. Bradycardia is probably normal for this patient ad she is a marathon runner.

3. Rauvan Averick - April 2, 2014

First of all, when is it not a busy day in my ED.
Bradycardia not unusual in a marathon runner. Hard to judge BP significance in this athletic woman, though it is toward the low side.
Will assume hyperextended position of neck while on racing bicycle is at the bottom of her symptoms.
Consider carotid artery dissection (even though no focal neuro sx) – would need to start with CTA of neck, or MRI; or hypersensitive carotid bulb – sx reproduced with mild carotid massage.

4. Bee Hall - April 2, 2014

Partial blockage of Carotid Artery?

5. Mike Jasumback - April 2, 2014

Carotid dissection

6. Laven - April 2, 2014

A: rule out ACS, PE, dissecting carotid, thoracic aortic aneurism

P: Cardiac enzymes, basic labs, chest xray, series ecgs and chest CT angiogram, consider carotid angiogram, closely monitor

7. Laven - April 2, 2014

Add to previous: head CT

8. VANAMALA P - April 2, 2014

GLOSSOPHARYNGEAL OR TRIGEMINAL NEURALGIA

9. Joao Carlos Almeida - April 2, 2014

Swallow syncope

10. J. Turpin - April 2, 2014

an arrhythmia that has resolved before first responder arrival.

11. PANKAJ ARORA - April 2, 2014

Carotid dissection +/- Aortic root dissection

12. T. Murphy MD - April 3, 2014

The working dx is : reflex syncope with bradycardia, which could be vasovagal, carotid baroreceptor sensitivity, carotid artery dissection, or myocardial infarction (even with normal ST segments) affecting the conduction system. The throat pain is concerning and could represent angina.
The patient needs ASA, serial enzymes, EKG’s and maybe 0.4 mg atropine. Beta blockers and nitrates for now would be contraindicated.

13. Misty Navarro - April 3, 2014

aortic dissection

All comments are held for approval.



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