Intern Report Case Discussion 2.6

intern-report

Presented by Claire Jensen, MD

CC: “She passed out,” per EMS.

HPI: A 63 year-old African-American female presents to the emergency department by ambulance following a witnessed syncopal episode at a casino.  Upon her arrival in the ED, the majority of the history is obtained from EMS as the patient is actively vomiting.  She was seated at a slot machine with friends when she suddenly slumped to the floor unconscious.  She did not complain of feeling ill and was acting normally prior to the syncopal episode.  Within seconds of landing on the floor, she regained consciousness.  Initially she was somewhat slow to respond, but was alert and oriented, responding normally by the time the paramedics arrived.  She vomited once, and was transported to the ED.  A blood sugar was obtained in the field, 130 mg/dL.  Upon arrival, she complains of “just not feeling well” and continues to vomit.  She also complains of severe headache “all over” and some blurred vision. She denies vertigo, chest pain, shortness of breath or abdominal pain.

ROS: Negative except as mentioned in the HPI.

PMH: Denies.

PSH: Denies.

Medications: None.

Allergies: None known.

FH: Hypertension.

SH: Life-long non-smoker, non-drinker, and does not use illicit drugs.

PE:

VITAL SIGNS: BP 200/104, P 102, R 16, T 36.3, SpO2 99% on room air.

GENERAL: Alert and oriented x3, initially answers questions appropriately, diaphoretic, moderate distress from vomiting.

HEENT: Head is atraumatic, normocephalic.  Pupils are 2 mm bilaterally and minimally reactive to light.  Mild disconjugate gaze is noted, with slight temporal deviation of the left eye.  No nystagmus.  No conjunctival injection or pallor.  No scleral icterus.  Funduscopic exam attempted but unable to perform due to the patient’s continued vomiting.  Tympanic membranes are normal.  No nasal drainage.  Moist mucous membranes, no tonsillar enlargement.

NECK: Supple without lymphadenolpathy.  There is no nuchal rigidity, no carotid bruits.

CARDIOVASCULAR: Tachycardic, normal S1, S2, without murmurs, rubs or gallops.

RESPIRATORY: Lungs are clear to auscultation bilaterally.

GASTROINTESTINAL: Abdomen obese, soft, non-tender, non-distended, without masses or organomegaly.  Bowel sounds present.

MUSCULOSKELETAL: Normal muscle bulk and tone.  No deformities.  Unable to perform muscle strength testing due to patient’s decreasing ability to follow commands.  She moves all extremities spontaneously.  Peripheral pulses are 2+ and symmetric in all four extremities.

NEUROLOGIC: Unable to assess orientation due to patient’s continued vomiting, The patient is noted to have increasing difficulty following commands.  Disconjugate gaze as noted above.  The face is symmetric.  DTRs were not assessed.  Babinski is down-going bilaterally.

Near the completion of the physical exam, the patient suddenly became unresponsive with snoring respirations and minimal gag reflex.  IV access was obtained, and the decision was made to intubate the patient so that emergent CT scan of the head could be obtained.

Questions

1.  This is the patient’s CT (without contrast).  What is the diagnosis?

________

A.  Brain tumom

B.  Epidural hematoma

C.  Interparenchymal hemorrhage

D.  Subarachnoid hemorrhage

E.  Subdural hemorrhage

__________

2.  Which medication should be considered for use as an adjunct to rapid sequence induction in this patient?

A.  Atropine

B.  Defasciculating dose of vecurionium

C.  Fentanyl

D.  Ketamine

E.  Morphine

__________

3.  A 49 year-old man presents after he fainted while running on his treadmill at home.  He has been having exertional dyspnea and angina for the past several months.  Which of the following cardiac diseases is most likely to cause these symptoms.

A.  Aortic stenosis

B.  Atrial septal defect

C.  Mitral incompetence

D.  Pulmonary stenosis

E.  Tricuspid incompetence

______________

Answers

1. D     Subarachnoid hemorrhage

2. C     Fentanyl

3. A     Aortic stenosis

Discussion

Syncope is defined as transient loss of postural tone followed by rapid and full recovery, typically upon assuming a supine position.  True syncope is an uncommon, yet recognized, presenting symptom of subarachnoid hemorrhage.  The differential diagnosis of syncope is incredibly broad, and potential etiologies range from the benign to the catastrophic.  The symptom of syncope itself can also be dangerous in that it predisposes the patient to traumatic injury.  As with any chief complaint, narrowing the differential begins with a thorough history and physical exam, and it is incumbent upon the emergency physician to rapidly integrate the information gleaned in order to be selective about which diagnostic modalities (and in what order) will best elucidate the root cause of the event.  A “shotgun” approach to the evaluation of syncope is low-yield and can actually slow the identification of the cause.

In this case, the patient presented with true syncope and was found to have subarachnoid hemorrhage secondary to aneurysm rupture.  Her complaints of severe headache and nausea and the physical findings of hypertension, disconjugate gaze and rapidly declining level of consciousness all support the diagnosis.  After management of airway, breathing and circulation, she was taken for CT of the head, which immediately revealed her diagnosis and allowed rapid mobilization of consulting services and definitive therapy.

Syncope is a common chief complaint in the ED, accounting for 1-3% of visits annually.  “Pre-syncope” or “near-syncope” accounts for yet more visits and should be considered on the same spectrum and approached similarly. Frequently, despite thorough evaluation by the emergency physician, a cause is not identified.  Therefore, risk stratification of the patient with syncope, taking into consideration co-morbid conditions and access to rapid follow-up, should occur simultaneously with diagnostic evaluation, as it ultimately impacts disposition.  The San Francisco Syncope Rule provides a simple mnemonic (CHESS) to assist the clinician in risk-stratification of patients presenting with syncope:

C – History of congestive heart failure

H – Hematocrit <30%

E – Abnormal EKG

S – Shortness of breath

S – Triage systolic blood pressure <90 mgHg

A patient with any one of these criteria is considered to be high risk for a serious outcome (death, myocardial infarction, pulmonary embolism, stroke, subarachnoid hemorrhage, significant hemorrhage, return to the ED or hospitalization for a related event.)  Various studies to validate the SFSR have reported sensitivities of 74-98%.

Clinical Pearls

  • The differential diagnosis of syncope is exceedingly broad.  A thorough history is the first step in narrowing the differential, with particular attention to other associated symptoms, and will guide the selection of diagnostic tests.
  • Pre-syncope is another common ED chief complaint, and often presents as “weak and dizzy.”  It is important to distinguish between pre-syncope and vertigo.  Both may be accompanied by headache, nausea, tinnitus, and other symptoms.  A useful tactic is asking the patient about a sense of the room spinning about them, which is indicative of vertigo.
  • Subarachnoid hemorrhage is one of the key “don’t miss” diagnoses in emergency medicine.  When reasonable clinical suspicion exists, a negative CT scan should be followed by lumbar puncture to satisfactorily exclude SAH.
  • Patients with subarachnoid hemorrhage can deteriorate rapidly and may require emergent airway management.  Lidocaine has traditionally been used as an adjunctive medication during intubation of patients with known or suspected elevated intracranial pressure to blunt further rise in ICP, although the studies to support this are few, limited, and sometimes equivocal.  Ultra-short acting opioids such as fentanyl are well-documented to blunt the sympathetic response  (and thus rise in ICP) to airway instrumentation and should be considered as well

Special thanks to Marjan Siadat, M.D. for her assistance with this case.

References

1. Bederson JB, Connolly ES Jr, Batjer HH, Dacey RG, Dion JE, Diringer MN, Duldner JE Jr, Harbaugh RE, Patel AB, Rosenwasser RH; American Heart Association. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke. 2009 Mar;40(3):994-1025. Epub 2009 Jan 22. Review. No abstract available. Erratum in: Stroke. 2009 Jul;40(7):e518.

2.  de Rooij, NK, Linn, FH, van der, Plas JA, et al. Incidence of subarachnoid haemorrhage: a systematic review with emphasis on region, age, gender and time trends. J Neurol Neurosurg Psychiatry 2007; 78:1365.

3.  Molyneux AJ, Kerr RS, Birks J, Ramzi N, Yarnold J, Sneade M, Rischmiller J; ISAT Collaborators. Risk of recurrent subarachnoid haemorrhage, death, or dependence and standardised mortality ratios after clipping or coiling of an intracranial aneurysm in the International Subarachnoid Aneurysm Trial (ISAT): long-term follow-up. Lancet Neurol. 2009 May; 8(5):427-33.

4.  Quinn J, McDermott D Stiell I, Kohn M, Wells G.  Prospective validation of the San Francisco Syncope Rule to predict patients with serious outcomes.  Ann Emerg Med. 2006 May; 47(5); 448-454.

5.  Birnbaum A, Esses D, Bijur P, Wollowitz A, Gallagher EJ.  Failure to validate the San Francisco Syncope rule in an independent emergency department population.  Ann Emerg Med 2008 August; 52(2); 151-159.

6. Rosen’s Emergency Medicine. Philadelphia: Mosby; 2010: 3-23, 142-148, 1333-1345, 1356-1366.

7.  Emergeny Medicine: A Comprehensive Study Guie.  McGraw-Hill; 2004: 108-118, 359-363, 1382-1389.

8.  Singer RJ, Ogilvy CS, Rordorf G.  Etiology, clinical manifestations, and diagnosis of aneurysmal subarachnoid hemorrhage.  Uptodate.com; 2010.

9.  McDermott D, Quinn J.  Approach to the adult patient with syncope in the emergency department.  Uptodate.com; 2010.

One Response

  1. 1. d 2. a 3. a

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