Call-out on Monday at 11:49am on a warm sunny morning with little wind. Male on Nab Scar route, feeling faint, unable to continue. During the approach to the casualty, who was just off path at around 290m, a radio message from passing walkers descending stated that the casualty had been unconscious for a short while. As you approach, what possibilities are you suspecting?
On arrival (12:23pm), the casualty, a male in his 60’s, is sat up against a grassy bank on gently sloping ground (Danger – none). He is talking with companion and passer-by (Response – conscious, coherent), and there is no sign of blood anywhere, not on him nor on the ground (Catastrophic haemorrhage – none).
Initial conversation establishes that he has no COVID symptoms and had had his second Pfizer jab 3 days previously. He has no pains or breathing problems and feels much better, although fatigued. He’s had fluids to drink since his collapse. As we elicit the story, we continue to assess him.
PRIMARY SURVEY
Airway Normal speech, so no need to further assess
Breathing Not breathless, but rate checked by hand on bottom of the sternum: 16/min – normal
Circulation Good colour, warm skin, cap refill 2secs on sternum, pulse good strength, 94/min regular
Disability moving all four limbs, speech normal, no facial weakness / drooping, all symmetrical
Environment/ Warm, no wind
Exposure
What do you think might have happened?
We continue with SAMPLE.
Symptoms He was climbing up Nab Scar, and began to feel faint and lightheaded. He collapsed and couldn’t remember anything more about the incident until he had come round.
His companion gave a clear account of the casualty becoming weak, holding himself up, then collapsing unconscious. He caught him and lowered him to the ground. He was unresponsive for around two or so minutes, with his eyes rolled back, then slowly regained consciousness, being confused and incomprehensible for a further 5 – 10 minutes.
There was no report of any shaking, jerking, or convulsions, nor any trauma during the episode. He’s 68 years old. He had a headache two days ago - the day after his second COVID jab- but nothing since.
Allergies No allergies
Medication Simvastatin (lipid-lowering); perindopril (blood pressure); amlodipine (blood pressure); diuretic (blood pressure)
Past History High blood pressure; (and by implication of medication, high lipids). No diabetes and non-smoker. He was a little overweight.
Last ate fluids within the last 30 minutes, snack mid-morning
Events As above
DIAGNOSES?
There are a few potential diagnoses to consider with the above story. What would you do next?
Strenuous exercise on a warm day could lead to dehydration, dilated blood vessels & low blood pressure and subsequent collapse – a faint. The history suggests that this is perhaps the most likely. His medications to lower his BP would make this more likely to happen.
However, in a 68yr old slightly overweight male with high blood pressure and high lipids, a cardiac problem would definitely be high on the list. He could have had a myocardial infarction (MI; heart attack) or heart rhythm abnormality – either too fast or too slow. He has 5 of the 8 main risk factors for MI (https://www.casualtycare.org/casualty-care#/heart-attack-angina/).
Without chest/arm pain, nausea, or breathlessness MI is less likely, but the consequences of missing the diagnosis are potentially very serious indeed.
Other conditions leading to sudden loss of consciousness would include hypoglycaemia, stroke/intracranial bleed, epilepsy or drugs. But with the above history, these are all much less likely. See text box at the end for more details.
MANAGEMENT
Given the potentially serious implications of the history, a decision was taken to request helicopter assistance. Meanwhile….
We used the Propac to obtain some more information. His BP was 139/78, P 94 regular, SpO2 94% on air (lowest acceptable limit in possible heart attack) but dropped to 93 and once to 92%. Erring on the side of caution, we gave him oxygen via a non-rebreathing mask at 6L/min, which quickly restored his O2 to 97%.
His ECG trace was normal.
HELIMED
After around 20 minutes, the Helimed team arrived and reassessed him. His observations, repeated by us at 5 – 10 minute intervals, were stable. They performed a 12 lead ECG, a much more thorough way of assessing for possible MI, and this was normal. They agreed with our view, and that he should proceed to hospital for full further assessment. They performed a BM test that showed a normal blood glucose. (As he had had sugary drinks since coming round, this result would not be of much value in making a diagnosis.)
We all speculated if he had had a reaction to his COVID immunisation and that this had in some way contributed to his episode.
OUTCOME
He was taken to hospital by ambulance, where they also concluded that he had fainted. However, one of the blood tests specific for heart muscle damage was abnormal, and they kept him in overnight for observation. He’s going to discuss the episode with his GP.
FOLLOW-UP
He sent us this text. I agree with him (and his family’s thoughts) about further investigations. Some individuals can damage the heart muscle by a surge in oxygen demand outstripping the body’s ability to supply it, and not a blockage to a coronary artery – a Type 2 MI.
Hi Roger, really pleased to hear from you, I was wondering how to get in touch and thank all of you guys, I thought you were all awesome.
Everything [at the hospital] checked out ok apart from I had a small troponin rise and they kept me in overnight. The consultant concluded that was spurious and I had fainted (vasovagal syncope) and I was discharged on Tuesday feeling fine. However, my daughter and son-in-law who are both GPs have put a little doubt in my mind because they think the troponin rise may need further investigation so I'm going to mention it to my GP. Thanks again to everyone, I'll try and behave myself next time. All the best.
MORE INFORMATION
Hypoglycaemia is very uncommon in a non-diabetic, and in hill-going individuals might rarely be caused by drugs or alcohol. Symptoms usually develop slowly, with sweating, anxiety, palpitations, confusion, weakness, dizziness etc, & rarely result in a sudden loss of consciousness. Moreover, spontaneous recovery would not be typical.
An epileptic fit or convulsion leading to loss of consciousness would usually be accompanied by several jerks or spasmodic movements of the limbs, and often in an individual with known epilepsy.
An intracranial bleed or stroke could lead to loss of consciousness, but would typically be marked by a variable degree of one-sided weakness of arm, leg or face or speech difficulty, which would persist. Very short-lived strokes can occur, with rapid resolution of the symptoms and signs, but these TIAs or “mini-strokes” would almost never lead to an isolated sudden loss of consciousness without the features outlined above.
LEARNING POINTS
· The history is often the most valuable way to make your initial diagnostic list, much more so than examination findings.
· The history from witnesses can be really valuable and complementary to that of the casualty.
Roger Barton, May 2021