19 Yom. CC was syncopable episode. Pt a/ox4 gcs=15 upon ems | Figure 1

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Case Summary

19 YOM. CC was syncopal episode. Pt a/o x4 GCS=15 upon EMS arrival. PT girlfriend states pt had approximately 30 seconds of unresponsiveness after complaint of feeling dizzy. PT initially refused all services even an assessment. Pt was able to be talked into full assessment but did not want transport due to not having insurance.

Pt states he thought he was hypoglycemic due to not eating breakfast and states 5 previous episodes in the last 3 months. After repeated request pt agreed to transport.

Initial Assessment: BP 128/76. 1st picture is initial 12 lead, ss slightly pale, cool, slightly clammy at core. Respiration 14, non-labored, SpO2 98%. BGL 64.

Initial Treatment: 16g in left AC. En route to hospital about 2 min from ER pt reports "I don't feel so good" has another syncopal episode lasting approximately 30 seconds (2nd picture: snapshot of 4 lead during syncopal). 3rd picture is 12 lead during syncopal. BP 58/P, ss: extremely pale, cool, diaphoresis. Pt given rapid fluid bolus, 0.5mg atropine IV, 14g IV in right AC with 2nd fluid bolus. BP improved to 112/68, 4 lead ECG ST at 120.

Per ER staff, pt labs were "completely normal". Pt became brady again at hospital, was given enough more atropine, pt did not want a bill so he snuck out of ER.

Discussion

Any ideas about what is going on?

Cases to consider:

Case 1: 19-year-old male patient at a minute clinic for school physical had a syncopal episode.

Case 2: 60-year-old male presenting with syncopal episode, treated with fluid bolus and activated STEMI.

Case 3: 39-year-old male presenting with symptomatic bradycardia and syncope after strenuously working in the heat.