Interesting case of syncope

[turkeyjerky]

Had an interesting case of syncope the other day that I wanted to run by you all. The patient was an otherwise healthy 50-something year old female BIBA for syncope. Story was that she was eating dinner and then 15 min later she experienced acute onset of generalized abdominal pain follow immediately by several episodes of vomiting and diarrhea. She then stood up from the toilet and felt lightheaded which was followed by syncope.

EMS arrived ~10 min later and found her to be lethargic. HR in the 50s with BP unobtainable (she had central pulses), she had received about 800 ml of saline enroute and upon arrival she was sitting up in the stretcher in no distress whatsoever. Vitals were significant for HR in low 50s and BP 96/30. Exam unremarkable other than diffuse erythroderma on trunk and extremities, which the patient says is "just how my skin gets sometimes".

Thoughts?

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[Apollyon]

What was she having for dinner? This suggests parasympathetic discharge via cholinergic stimulation. Was that erythema cholinergic urticaria?

She had the DGE of "SLUDGE". No one served sarin, soman or tabun with the ramen, did they? Then again, if they did, then she wouldn't be "in no distress whatsoever".

(Medical/scientific humor is SO nerdy.)

 

[pianoman511]

Something she ate disagreed with her and she had vasovagal syncope.

 

[Arcan57]

No, she was eating seafood.

 

[Tiger26]

Was she eating fish?

 

[deleted547339]

Was she eating fish?

And did it taste peppery?

 

[namethatsmell]

Exam unremarkable other than diffuse erythroderma on trunk and extremities, which the patient says is "just how my skin gets sometimes".

Did this resolve spontaneously during her stay in the ED?

 

[Birdstrike]

Scromboid/ciguatera poisoning

 

[WilcoWorld]

I like scombroid for a diagnosis, but with sudden onset of abdominal pain -> syncope -> hypotension my first concern is going to be a ruptured AAA. If the patient is looking better on arrival, it might mean that the leak has been tamponaded (temporarily). I would start with IV access x 2, a type & cross and a bedside US. However, the erythroderma strongly suggests something immunologic, so I'm not going to call the vascular surgeon just yet.

To Birdstrike's ciguatera point, I'd like to ask if there were any neuro symptoms?

 

[illegallysmooth]

Had an interesting case of syncope the other day that I wanted to run by you all. The patient was an otherwise healthy 50-something year old female BIBA for syncope. Story was that she was eating dinner and then 15 min later she experienced acute onset of generalized abdominal pain follow immediately by several episodes of vomiting and diarrhea. She then stood up from the toilet and felt lightheaded which was followed by syncope.

EMS arrived ~10 min later and found her to be lethargic. HR in the 50s with BP unobtainable (she had central pulses), she had received about 800 ml of saline enroute and upon arrival she was sitting up in the stretcher in no distress whatsoever. Vitals were significant for HR in low 50s and BP 96/30. Exam unremarkable other than diffuse erythroderma on trunk and extremities, which the patient says is "just how my skin gets sometimes".

Thoughts?

I like scombroid for a diagnosis, but with sudden onset of abdominal pain -> syncope -> hypotension my first concern is going to be a ruptured AAA. If the patient is looking better on arrival, it might mean that the leak has been tamponaded (temporarily). I would start with IV access x 2, a type & cross and a bedside US. However, the erythroderma strongly suggests something immunologic, so I'm not going to call the vascular surgeon just yet.

To Birdstrike's ciguatera point, I'd like to ask if there were any neuro symptoms?

I was thinking AAA then realized pt was brady, should be tachy. Still agree with the bedside plan tho.

 

[EMdoc10]

Paradoxical brady by peritoneal-blood irritating vagus? (similar to how it may in ruptured ectopic)

 

[illegallysmooth]

Paradoxical brady by peritoneal-blood irritating vagus? (similar to how it may in ruptured ectopic)

Interesting. After initial fluids, however, she was sitting upright in no distress. Not c/w generalized peritonitis, right? If it's an AAA, shouldn't bleeding should be retroperitoneal?

Anyone considered mesenteric ischemia? Seems unlikely the pt would revert to zero distress, tho.

 

[golghiapparatus]

Anaphylaxis? Did she get any meds by EMS?

 

[deleted109597]

Porphyria

 

[Apollyon]

Only a few of you are addressing the skin symptoms. AAA that has happened several times before, and erythematous skin, and resolution? That would, minimally, be singular and unique. Scombroid and cholinergic urticaria I think are much more likely.

 

[WilcoWorld]

To be clear, I'm not saying that I think it's AAA. I'm saying that, as an ER Doc, that's the first thing I want to rule out.

 

[USCDiver]

Lupus

 

[turkeyjerky]

Great responses! I didn't really consider AAA as the patients belly pain had completely resolved and her exam was benign scombroid was a consideration but there was no fish in her meal. So, with the acute onset of multisystem involvement (gi, skin and cardiovascular) following a potential allergen exposure, I elected to treat empirically for anaphylaxis.

The patient was a weirdo though, and refused treatment other than IV fluids. Over the next six hrs her BP slowly normalized, HR went up to mid 80s and her rash disappeared. labs were significant for a pretty profound hypoK (2.5) which seems disproportiate to a few episodes of acute vomiting and diarrhea. I have no idea whether this was just a vasovagal reaction to some food poisoning, or self-limited anaphylaxis. Calling it syncope though, is a bit of a misnomer given the prolonged duration of symptoms.

 

[Apollyon]

Great responses! I didn't really consider AAA as the patients belly pain had completely resolved and her exam was benign scombroid was a consideration but there was no fish in her meal. So, with the acute onset of multisystem involvement (gi, skin and cardiovascular) following a potential allergen exposure, I elected to treat empirically for anaphylaxis.

The patient was a weirdo though, and refused treatment other than IV fluids. Over the next six hrs her BP slowly normalized, HR went up to mid 80s and her rash disappeared. labs were significant for a pretty profound hypoK (2.5) which seems disproportiate to a few episodes of acute vomiting and diarrhea. I have no idea whether this was just a vasovagal reaction to some food poisoning, or self-limited anaphylaxis. Calling it syncope though, is a bit of a misnomer given the prolonged duration of symptoms.

Even if there was no fish, was there anything hot and spicy, or did you not go into that much detail? Did you check her magnesium level? Did you refer her on to allergy and immuno?

I'll bet you that this is something beyond vasovagal, interesting, but also benign.

 

[turkeyjerky]

Even if there was no fish, was there anything hot and spicy, or did you not go into that much detail? Did you check her magnesium level? Did you refer her on to allergy and immuno?

I'll bet you that this is something beyond vasovagal, interesting, but also benign.

It was some sort of rich casserole with mayonnaise and eggs, not sure if it was spicy. Why do you ask? And, yeah mag was low too (1.1). I did advise her to seek a referral to an allergist through her pcp (we don't have them on our referral list).

 

[Apollyon]

It was some sort of rich casserole with mayonnaise and eggs, not sure if it was spicy. Why do you ask? And, yeah mag was low too (1.1). I did advise her to seek a referral to an allergist through her pcp (we don't have them on our referral list).

First, good catch on the mag - you can't fix low K if there is a low mag that is not repleted first, as the sodium potassium pump is magnesium dependent. As to the spicy, that can trip off an attack of cholinergic urticaria.

When you check the mag and it is normal, so what - but, when it is low, you look like a hero (as it is is that "things not looked for are rarely found").

And I am not surprised that you don't have A&I on the call list - getting to one through the PCP is the way you'll do it in practice.

 

[Rendar5]

Did you have her sign out AMA for refusing electrolyte repletion/correction? Hard to say you ruled out arrhythmia as a cause for syncope when you've got a fair amount of disturbance with the K/Mg

 

[gman33]

Did you have her sign out AMA for refusing electrolyte repletion/correction? Hard to say you ruled out arrhythmia as a cause for syncope when you've got a fair amount of disturbance with the K/Mg

Unless she got admitted, I'd sign this one out AMA every time.
If that provides any real protection is a whole other story.

The rash makes me think this was allergic, at least to some extent.

 

[It'sElectric]

Not to derail, but what are others' opinions on AMA forms? A few of my super smart mentors in residency (infinitely smarter than me at least) taught me to believe that they were essentially BS and provided zero protection. They never had people sign out AMA, but they always documented that the pt was leaving against medical advice (i.e. discussed risks including death, blah blah. Pt was informed chose to go home against medical advice). Same thing?

 

[Rendar5]

The form is there to prove that you're not lying when you say the patient left AMA. The real AMA paperwork is your documentation that the patient made a decision that you clearly did not agree with and that they really understood the risks.

 

[EM2BE]

The form is there to prove that you're not lying when you say the patient left AMA. The real AMA paperwork is your documentation that the patient made a decision that you clearly did not agree with and that they really understood the risks.

I also have a family member sign if they are present and taking them home. Just with the hope that if something bad does happen, the family can't say the patient wasn't of sound mind or some other BS reason the patient should not have been allowed to sign out. I really hope if it comes to it, that will help me.