Case Presentation by Dr. Craig Sharkey, MD
HPI: 43 year old male brought in by EMS for altered mental status. History provided by EMS: Patient was at home, drinking alcohol. He was found by family at the bottom of the stoop. Family notes that although he was drinking, he did not appear intoxicated. He had been at his normal state of health prior to the incident. No further history can be obtained; family is on their way via private vehicle.
ROS: Unable to assess
PMHx: Unknown, per EMR: none
PSHx: Per EMR: none
Family History: Uncle died in 30s from heart attack
Social: + Alcohol
VS: T 36.5 BP 141/90 P 80 RR 18 SpO2 99% on 15 lpm via nonrebreather mask
General: Patient minimally responsive. Not warm to touch, nondiaphoretic. Gag intact, has spontaneous respirations.
Head: NCAT, no obvious external hematoma or abrasion
ENT: dried blood at nares, trachea midline, no JVD
Eyes: Pupils mid range, responsive to light, extraoccular movements unable to be assessed
CV: Regular rate and rhythm. No murmur/rub/gallop appreciated. 2+ radial and DP pulses appreciated.
Pulm: Clear to auscultation bilaterally. No wheeze/rhonchi/rales
GI: soft, nontender, nondistended. Bowel sounds appreciated.
MSK: No deformity
Neuro: Initial GCS 3. During initial exam, patient becomes arousable. He is able to say his name, but does not know the day/year/location. He would obey commands to move arms and legs, no gross focal deficit.
Chem 7: 140/3.7/102/28/13/1.3/8.7
CT head/c-spine: Negative
On review of EMR, his last presentation was 9 years prior
1) On repeat exam, he is still normotensive, no tachycardia. He has no current complaints of chest pain, dyspnea, dizziness, palpations, nausea. Given the patient’s presentation what is the most appropriate disposition:
a) Activate cardiac cath lab for suspected acute myocardial infarction, given his EKG changes.
b) Trend troponin, place in CDU for chest pain rule out and provocative testing for suspected underlying coronary artery disease.
c) Place in TCU pending sobriety and trend troponin.
d) Admit to cardiology on telemetry for sudden death prevention
2) While in the emergency department, he becomes unresponsive and the monitor is alarming. He is pulseless and the monitor is displaying a wide complex tachycardia. Your next action is:
a) defibrillation followed by 1.5 mg/kg lidocaine for V-tach prophylaxis
b) synchronized cardioversion followed by 1.5 mg/kg lidocaine for V-tach prophylaxis
c) synchronized cardioversion, admit patient for AICD placement
d) synchronized cardioversion, admit to MICU with toxicology consult
3) The pathology underlying his presentation is likely:
a) alcohol abuse, dehydration and electrolyte abnormality
b) membrane ion channel dysfunction
c) luminal defects in the coronary arterial circulation
d) undisclosed polysubstance abuse with adulterant
1) D: This patient presented with syncope and an EKG that is typical of Brugada Syndrome. He underwent cardiac catheterization that was normal. Electrophysiology was involved later in the course and placed an AICD in the patient. While it is common for these patients to undergo cardiac catheterization, he ultimately needs sudden cardiac death prophylaxis.
2) C: The patient requires electrical intervention for his decompensation; defibrillation or cardioversion would be effective. He should not receive any sodium channel blockade as this will possibly exacerbate the underlying brugada pathology. Lidocaine and procainamide in particular are used in the EP lab as a provocative drug challenge to assess for Brugada syndrome. Brugada syndrome can be unmasked with a variety of events such as fever, alcohol, cocaine, or other medications. The EKG can change markedly depending on these factors.
3) B: Brugada syndrome is typically thought to be due to an autosomal dominant mutation in the SCN5A sodium channel gene. This is found in 18-30% of families with Brugada syndrome. Other sodium and calcium channel genes have been implicated as the causative factor in SCN5A negative patients. This patient and his first degree relatives were tested for this genetic mutation.
Brugada syndrome: See figure 1 for diagnostic criteria.