3-118
Objective: Signs
Using Basic Tools: Cool, clammy skin; depressed consciousness; weak pulse and hypotension. Tonic-
relaxation movement of the extremities (forceful muscular contraction followed by passive relaxation) repre-
sents hypoperfusion seizures, not tonic-clonic epileptic seizures. Neurologic exam: assess patient according
to Glasgow Coma scale (GCS) (see Appendix) if not fully conscious.
Using Advanced Tools: Lab: Urinalysis for glucose, hematocrit for anemia, EKG for arrhythmia.
Assessment:
Differential Diagnosis
Acute myocardial infarction - ST elevation on EKG
Rhythm disturbance - EKG shows tachycardia >180, bradycardia <40, ventricular tachycardia
Seizure Disorder - Evidence of tongue biting, urinary and bowel incontinence
Hypoglycemia - ChemStrip urinalysis positive for ketones in starvation, diabetic ketoacidosis (DKA), others; in
DKA, urine should be positive for glucose also (glucose in blood, but cannot be absorbed by cells)
Hypovolemia - Tilt test positive with BP dropping >20mm and HR rising >10 bpm
Psychiatric - consciousness returns abruptly if nose and mouth are held closed
Many medications can cause a loss of consciousness, especially if taken in combination with alcohol.
Alcohol and recreational drugs are also a leading cause of loss of consciousness in young persons without
a history of previous syncope.
Heat injury - history of exposure; other patients from unit
Plan:
Treatment
Primary:
- Protect patient from injury and place with feet elevated.
- Protect airway: a good rule of thumb: on GCS, less than 8, intubate.
- Start IV and deliver D5NS bolus infusion of 500 cc. Continue 200 cc/hr until systolic BP >90.
- Determine EKG rhythm. If HR >150 and QRS is greater than three little boxes and the patient is
hypotensive, defibrillate as for ventricular tachycardia. If the HR is >200 and the QRS is less than three
little boxes, bolus with 500 ml NSS and give propranolol 0.1 mg/kg IV. If the rhythm is sinus and less
than 50 bpm, give 1mg Atropine IV and may repeat in 5 minutes or until the HR rises above 70. If
propranolol IV is used, start on propranolol 40 mg qid. If Atropine IV is used, place transdermal
scopolamine patch. - If hypoglycemia is suggested by the ChemStrip or the history, give a bolus of D50 IV.
- If no response to above, give Narcan 1 ampoule IV.
- If patient is seizing, see Neurology: Seizure Disorders.
NOTE: Ventricular tachycardia that responds to lidocaine should be treated as Unstable Coronary Syndrome.
Primitive: Elevate the feet and cover with warm blanket.
Empiric: Start IV with NSS as a bolus of 1000ml and give 1 ampoule of Narcan if member remains
unconscious.
Patient Education
General: A simple faint may be vasovagal and is not serious. If recurrent (more than one per month) or
results in bodily injury, then see consultant for preventive medications. When an aura occurs, lie down or sit
down and place your head between your knees.
Activity: Patient should not stand duty alone for 48 hours. They should not jump; drive or dive after the
second event until they have been further evaluated at a higher echelon of care.
Diet: No salt restrictions, drink plenty of fluids, restrict refined sugars, avoid alcohol.
Medications: Propranolol may cause tiredness; scopolamine may cause dry eyes and dry mouth (urine
retention in males).
Prevention and Hygiene: Maintain hydration. Advise unit to prevent other heat or drug related injuries.
No Improvement/Deterioration: Return for reevaluation promptly, particularly if problem recurs.