Clinical Case 045: Syncopal Salesman
37 yo man who works as a travelling sales rep. He has a hectic lifestyle and is overweight. Flies around the country a lot visiting hospitals selling medical equipment. He presents via ambulance after having a syncopal episode in the local McD’s.
The event was witnessed by a client and staff at the restaurant – he was a bit sweaty, got up to go to the bathroom and fell, he narrowly avoided hitting his head on a chair as he collapsed to the ground. No seizure activity, incontinence or neurolgical deficit noted at the scene. He was unconscious for about a minute. When the ambos arrived 5 minutes later he was GCS – 15, oriented, though seemed a ‘bit vague’.
Whilst in your small country town for a 3 day visit he notices that he has become increasingly “unwell” – he can’t really put a finger on it -he says he “has been hazy in the head” and “feeling like nothing seems real” for the last 48 hours. No specific vertigo symptoms, headaches or pre-syncopal events have been noted.
Hypertensive – was on ramipril, but stopped taking it as it interfered with his ‘performance’
Smoker – 10 -15 per day
1 episode of gout effecting MTP jt
Depression – currently on 40 mg paroxetine/day, good response to this and supportive therapy from GP
Dyslipidemia – trialing “diet and exercise”
Obs: pulse = 85 reg, BP 145/90 no postural drop, SpO2 = 99% RA, RR 14/min, no clinical pallor, anaemia etc
Otherwise his heart, chest, neuro, abdo etc are all normal.
What specific negatives do you want to ensure on physical examination?? What can you exclude by looking and listening?
ECG – normal, sinus rhythm, maybe borderline for LVH criteria, normal axis.
What specific features / conditions do you want exclude / or see on the resting ECG in a man with syncope?
Urninalysis is = SG 1.015, 1+protein, otherwise normal
pH 7.41, lactate 0.4 mmol He has a Hb of 156 g/l
Electric lights are all normal
Nothing to write home about… What were you hoping not to see ?
OK, that is it for now. At this stage I will tell you that any further tests that you want to do are either negative or unavailable in our little ED scenario.
The diagnosis is out there… first prize goes to the reader who asks the right questions to solve the puzzle.
Ready, set, go…. write your thoughts on the comments and I will respond
Clinical Case 072: The Difficult Airway that Wasn’t
Rural Trauma Podcast: Emergency Trauma Management Course
Clinical Case 140: Rapid POCUS Diagnosis
About The Author
Casey Parker
I am a GP working in Broome, NW of Western Australia. I work as a hospital DMO (District Med Officer) doing Emergency, Anaesthestics, some Obstetrics and a lot of miscellaneous primary care. Also on the web as @broomedocs | + Casey Parker | Contact
Whats his medical history? Medications? Allergies?
I suspect his physical exam will be unremarkable, right?
ECG please. BSL. UA. Baseline bloods, including troponin, electrolytes.
smells cardiac…or drug related.
Aw shucks. I’ll have a stab
Even in the busy ED at 3am, I’ll try and take a history encompassing bio-psycho-social factors
Past Medical history?
Medications and allergies? Inc illicit/recreational and OTC meds
Family history?
Social history?
Push him hard n risk factors for cardiac or neuro disease.
Explore stressors – financial & work particularly
Exam – geenral appearance. Addisonian? Cardiac and neuro exams in detail. Carotids?
ECG useful
I wanna know his obs. If I’m feeling cheeky I’d like to know bloods from iStat
What does HE think is causing it?
Differential at this stage is huge
Feed us some more info (and I reckon history will be the clue) and see if we need any more fancy Ix like CT head, 24hr tape etc…
All the above but my top differential is PE.
CT angio please
We have access to a CT angio in Broome. But, he is PERC negative with a low risk Wells score.
In the absence of any chest pain, dyspnoea, cough etc this seems like a bad call.
Remember the relatively high rate of false positive that CTPA produces means you might be condemning him to warfarin for no good reason
So no imaging was done. Anybody out there think his is foolhardy or cavalier? Let me know
Casey
CT angio? In Dingo Creek? You’re having a laugh aren’t you?
My ED when I arrived consisted of a few old IVs and a piece of string…the first time I asked for a chest tube I was given a urinary catheter…
Things are a LOT better now. But I reckon a CT angio in Dingo Woop-Woop is pushing it.
Bedside ultrasound? There’s a maybe…
I’d be curious about his sleep quality – does he have apnea? Also, how’s his renal function?
Great thought. I reckon sleep apnoea is one of those common but oft-forgotten diagnoses that can turn up in a lot of scenarios.
It should be a routine question in pre-anaesthetic clinic, but it aint!
But, no -he had no SSS or history of sleep apnoea
However, he had not been sleeping well – tossing and turning a lot!
Casey
Diet and exercise, year right! He collapsed in Macdonalds! Oh I forgot you can order a salad there…lol. Paroxetine..it must be something to do with that. Its not a popular antidepressant anymore due to the withdrawal syndrome.
Questions
Did he run out of paroxetine or forget to take it for a few days?
Did he take any over the counter medicines that could interact with paroxetine, in particular antihistamines.
I’m picking up some neuro notes on the nose here.
Call Oliver Sachs.
Ask him how many elephants there are in Belgium.
Are things appearing small?
Alice in wonderland syndrome?
Tumour or bleed, somewhere……
Full+++ exam, fields, etc.
Don’t ask Oliver Sachs how many bloody elephants there are.
What the…..
With HTN and LVH, I’d like to know whether he’s got the narrow pseudo Q waves in the lateral chest leads of HOCM. Is he dehydrated? If so, it will be more likely to be symptomatic.
If that doesn’t help, even though he’ll be PERC negative, being a fat man on a plane I’d want to know what’s the CT-PA result.
HOCM – good thought. Does the absence of a murmur make this unlikely?
Tough to exclude in ED. If you are a keen ECHo doc you might be able to see it, but anybody happy to rule it out?
Re: CTPA – see above reply to JB. Not going there personally
Syncope me screams either neuro, cardiac or drug related
ECG is the single best investigation to do here with no bloods or CT
-> looking to exclude Long QT, WPW, Brugada, HOCM (See Amal Mattu’s talk on Syncope), VT, ischaemia
-> http://www.emrap.tv/index.php?option=com_content&view=article&id=2206
Examination you could exclude hopefully exclude a cerebrovascular cause in the neurological exam also any toxidromes such as a serotonergic or anticholinergic . CVS – rule out tachyarrythmias, acute valvular lesions
Hmmmmm
Fat man goes to ground. Normal ECG, normal neurological and CVS exam. Hazy in the head, could this be a metabolic or drug related issue?
Did he stop taking his paroxetine? (Minh already asked)
Causes of syncope are commonly postural hypotension, cardiovascular or cerebrovascular (rarely)
Postural hypotension:
History is always all important – what was he doing at the time? already standing, just stood up? eating? micturating? was he wearing a tight collar?
Lying / standing BP would be very important
Cardiovascular:
Ischaemic – high pretest probability, though no ECG changes would go against this.
Valvular – Ao sten (M sten less likely). should be picked up by clinical exam. Was the pulse slow rising? Was the aortic second heart sound easily heard? LVH would be in keeping. Atrial myxoma. (echo would be very useful.)
Arrythmia. A completely plum normal ECG would go against this, but usually most ECGs that are reported as normal in ED are not! consider WPW, VT, Brugada, bradyarrythmia, polonged QT (paroxetine)
Hypertensive encephlopathy – consider phaeochromocytoma with episodic hypertensive changes (LVH on ECG and possible renal involvement WTU – protein) What was on the fundi?
Cerebrovascular:
vertebrobasilar ischaemia (? diplopia, ataxia, vomiting, nystagmus)
I agree PE is possible but unlikely to have such a large PE with no other features (though not impossible, so I would investigate further if nothing else showed up.)
Great site Guys, though I trained for my FJFICM up in queensland I have a fondness for western australia and the kimberley.
Mat
CAD
Any palpitations, chest discomfort or dyspnea during these episodes? If so, 24 h Holter monitoring.
CBC? Electrolytes (Na low?)?
Does the parents or sibling have any diseases?
He’s young, but maybe a USG of he’s carotids.
Did he fell unhappy and took some extra doses of paroxetine?:)
I think there are 2 keys here. He felt sweaty BEFORE standing up, following which he had what sounds like a hypotensive episode. The other is that he has been unwell for a few days.
Withdrawal effects of SSRIs as per AMH
– dizziness, nausea, paraesthesia, anxiety, agitation, tremor, sweating, confusion, electric shock-like sensations
– more common with paroxetine and least likely with fluoxetine
Cardiac causes would be my first guess in real life, but given the other comments I will punt on SSRI withdrawal.
For those of us who prescribed Paroxetine in its time of popularity, will recall the acute withdrawal issues that plagued our patients on it who were trying to change to another medication or cease it. It is the hardest antidepressant to cease due to this issue.
that is why I was immediately suspiscious of the Paroxetine being the root cause of this man’s problems. Nowadays you dont often see it prescribed so many in clinical practice may have never seen this issue.
if you work in ED or critical care predominantly you may never have seen this syndrome.
What about PE?
I almost forgot a rythm disturbance Torsades?VT? long QT?
A bit more on social history, job situation, life stressors etc?
The hint that tests etc will mostly be normal makes me think of usually unlikely DDx’s;
Psychogenic syncope, dissosciative disorder, panic disorder.
Great blog! Very difficult but enjoyable cases!
Case 045: the Answer
Congrats to Minh le Cong, he was first in to ask the big question that clinched the diagnosis…
The patient was on a good dose of paroxetine, and let it home. He then went out all night drinking and ended up in a fast food restaurant having not eaten for 12 hours
Combination of these factors I think is enough to make the diagnosis.
The tests were all normal, the dangerous diagnoses were either not there or too unlikely to need consideration.
A: SSRI withdrawal with too much grog, dehydration leading to transient syncope
Obese hypertensive with syncope-chance of arrhythmia is high.i would opt for holter monitoring