Recurrent collapse in a 56-year-old truck driver

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Problem 30 Recurrent collapse in a 56-year-old truck driver

A 56-year-old truck driver presents to the emergency department with a 6-month history of recurrent episodes of loss of consciousness. He has had four episodes in total and his most recent event occurred while he was driving his vehicle. Luckily he was not seriously injured. You are the attending doctor in the emergency department and are assessing him.

Q.1

What specific questions would you ask the patient and what are the possible causes of syncope?

On further questioning you find out that the patient’s episodes are unprovoked and come on at any time without warning. There is no postural element to the symptoms and they are not exertional. He denies any urinary or faecal incontinence during the attacks and makes a prompt recovery following events. His wife has witnessed the attacks and tells you that there are no associated seizure-like movements. Until now he has not injured himself as a result of the syncopal attacks. In between attacks he has been systemically well. He has not had any recent headaches or head injuries and denies any abdominal symptoms or unplanned weight loss. He denies any chest pain or shortness of breath and there is no history of sudden cardiac death within the family. He seldom drinks alcohol, does not smoke and denies any history of illicit drug use. He is not taking any regular medications.

Q.2

What would you look for on physical examination?

Physical examination is essentially unremarkable with no abnormal cardiovascular findings and a normal neurological exam. The only positive finding is that of centripetal obesity consistent with the patient’s elevated body mass index. You request an ECG in light of the normal physical examination (Figure 30.1).

Figure 30.1

Q.3

What does it show and what else would you look for on the ECG? What further investigations would you consider requesting in a patient presenting with syncope?

Following a period of overnight cardiac monitoring that was essentially unremarkable our patient was discharged home for further outpatient evaluation.

Q.4

The results of initial investigations fail to provide a definitive cause for the syncope. What other investigations could you suggest?

The patient went on to have a 24-hour ambulatory cardiac monitor. He had several episodes of syncope during this time. Figure 30.2 shows the electrocardiogram during the events.

Figure 30.2

Q.5

What does the ECG strip show and what would you do now?

Based on this information, your patient is admitted to hospital and has a dual-chamber pacemaker inserted without complication and recovers well at home. Dual-chamber pacing is preferred over single-chamber left ventricular pacing as it is more physiological and associated with fewer long-term adverse sequelae. Another option, as the patient had sinus node disease, would have been to implant a single-chamber atrial lead. However, given the conduction system disease on his resting ECG it was felt that a ventricular lead should be inserted because of the risk of developing bradycardia due to atrioventricular node/His–Purkinje dysfunction in the future.

An important consideration in any patient presenting with syncope is their suitability to drive a vehicle following the attack. These will vary depending on state or country and will also depend on the type of licence that the patient holds. Generally, patients with a commercial vehicle licence have more stringent regulations placed upon them than patients with a private licence.

Your patient is discharged on the day after pacemaker insertion, with advice to observe the pocket site for infection, and follow-up pacemaker check in 3 months’ time.

Answers

A.1 When approaching a patient presenting with loss of consciousness it is important to use the history to attempt to derive the most likely diagnosis. It may be appropriate to speak to a family member in order to obtain as much collateral history as possible since the patient may have difficulty recalling the situation.

Firstly, the patient’s demographic provides an important clue in the diagnosis. Vasovagal syncope is more common in young patients although syncope in the elderly has a greater risk of adverse outcomes. Also, knowing the situation in which the syncopal event occurred is important. For example, if the patient has been standing for a long time in a hot environment prior to losing consciousness or has a syncopal event following (not during) exercise, again this is suspicious for a vasovagal episode.

Does the patient have a characteristic warning prior to the syncope? Patients with vasovagal syncope classically have a prodrome that consists of a lightheaded sensation, feeling nauseous and diaphoretic prior to the attack. An absence of a warning prior to the episode of loss of consciousness often indicates a more sinister aetiology such as a cardiac arrhythmia.

Syncope occurring soon after standing suggests orthostatic hypotension that may occur on its own or be a part of a systemic process such as autonomic neuropathy. It is worthwhile enquiring what medications the patient is taking as new medications such as diuretics and anti-hypertensives can augment the postural hypotensive response.

A history of headache prior to syncope should make you think of a subarachnoid haemorrhage as a potential cause. Diplopia and vertigo may suggest brainstem ischaemia from cerebrovascular disease; however, syncope is uncommon in anterior circulatory cerebral ischaemia.

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