1. Interesting Case

2. 82 year old man Brought in to RAZ by EMS Brought in to RAZ by EMS

3. Presenting Complaint (nursing notes) “Ground level fall at 13:15 today. Unresponsive for 3 minutes after fall. No seizure, but incontinent of urine. Witnessed by wife.”

4. What do you want to know?

5. BP 121/71 BP 121/71 HR 76 HR 76 RR 18 RR 18 O2 95% on 2 liters O2 95% on 2 liters T 36.7 T 36.7

6. Patient awake Confused Not oriented to place or time Doesn’t remember what happened

7. Fortunately… His wife is there His wife is there

8. Unfortunately… She’s almost as confused as he is She’s almost as confused as he is She can tell you what happened, though She can tell you what happened, though

9. History Shopping – fell backwards while walking. Shopping – fell backwards while walking. No prodrome No prodrome Hit back of head on floor Hit back of head on floor

10. Past Medical History Two recent falls in the past month – wasn’t seen in hospital for these Two recent falls in the past month – wasn’t seen in hospital for these Dementia Dementia Rarely sees a doctor Rarely sees a doctor No medications No medications

11. On exam T 36.7 HR 76 RR 18 BP 121/71 O2 95% on 2 liters T 36.7 HR 76 RR 18 BP 121/71 O2 95% on 2 liters CN exam normal CN exam normal Hematoma right occiput Hematoma right occiput HR regular, no murmur HR regular, no murmur Wife thinks slightly more confused than usual Wife thinks slightly more confused than usual

12. What next? What next? Any concerns? Any concerns? Differential Dx? Differential Dx?

13. Time to move Time to move Needs a monitored bed Needs a monitored bed

14. Investigations? Investigations?

15. Investigations CBC, Lytes, Creatinine, Glucose, Mg, Phosphate, Calcium, Troponin CBC, Lytes, Creatinine, Glucose, Mg, Phosphate, Calcium, Troponin ECG ECG CT head and C-spine CT head and C-spine

17. ECG RBBB RBBB Left Anterior Fascicular Block Left Anterior Fascicular Block

18. CT CT C-spine normal CT C-spine normal Cleared C-spine precautions Cleared C-spine precautions

19. CT head

20. CT Head Report Intraparenchymal hemorrhage involving bilateral posterior parietal lobes at occipital junction Intraparenchymal hemorrhage involving bilateral posterior parietal lobes at occipital junction Small SAH right frontal lobe Small SAH right frontal lobe No midline shift No midline shift

21. Meanwhile… Patient ticking along happily until… Patient ticking along happily until…

22. I hear some commotion… Patient is slumped over and the monitor shows this rhythm Patient is slumped over and the monitor shows this rhythm

24. Asystole! Asystole! ! ! !

25. Spontaneous Resolution Spontaneous Resolution Get the crash cart Get the crash cart Pads put on Pads put on

26. Quickly now… Let’s have a talk about Level of Care Let’s have a talk about Level of Care Full bore ahead Full bore ahead

27. Who ya gonna call? A. Ghostbusters A. Ghostbusters B. Your Mom B. Your Mom C. The laundromat (underwear feels sort of damp) C. The laundromat (underwear feels sort of damp) Cardiology Cardiology

28. Next step Transvenous Pacer Transvenous Pacer Patient agitated – required some sedation, but procedure otherwise successful Patient agitated – required some sedation, but procedure otherwise successful

29. Syncope “Sudden transient loss of consciousness associated with inability to maintain postural tone.” “Sudden transient loss of consciousness associated with inability to maintain postural tone.”

30. Syncope 1-3% of all ED visits 1-3% of all ED visits 1-6% Admissions 1-6% Admissions

31. Causes Vasovagal, Carotid sinus syndrome Vasovagal, Carotid sinus syndrome Neurologic – SAH, Subclavian steal Neurologic – SAH, Subclavian steal Medications Medications Orthostatic hypotension Orthostatic hypotension Pulmonary Embolus Pulmonary Embolus Cardiac Cardiac

32. Cardiac Syncope 1. Structural – Aortic Stenosis, Cardiomyopathy, MI 1. Structural – Aortic Stenosis, Cardiomyopathy, MI 2. Dysrhythmias – Brady and Tachy 2. Dysrhythmias – Brady and Tachy

33. Bradysrhythmias 2 nd or 3 rd degree heart block 2 nd or 3 rd degree heart block Sinus node disease Sinus node disease Pacemaker malfunction Pacemaker malfunction

34. Tachydysrhythmias Ventricular tachycardia SVT A Fib A Flutter

35. San Francisco Syncope Rules CHESS CHESS C – History of CHF C – History of CHF H – Hematocrit < 30% H – Hematocrit < 30% E – Abnormal ECG E – Abnormal ECG S – Shortness of Breath S – Shortness of Breath S – Systolic Blood Pressure < 90 S – Systolic Blood Pressure < 90

36. “Abnormal ECG” Dysrhythmias Dysrhythmias WPW WPW Brugada Brugada Prolonged QTc Prolonged QTc Any new abnormality Any new abnormality

37. Boston Syncope Rules Broad set of rules – 25 criteria Broad set of rules – 25 criteria Misses our patient Misses our patient

38. Short-Term Prognosis of Syncope (STePS) 4 Independent predictors – 4 Independent predictors – 1. Abnormal ECG 1. Abnormal ECG 2. Concomitant trauma 2. Concomitant trauma 3. Absence of prodrome 3. Absence of prodrome 4. Male gender 4. Male gender

39. Back to our patient Admitted to Cardiology Admitted to Cardiology Transferred to Foothills for permanent pacer Transferred to Foothills for permanent pacer Slow to recover from anaesthesia and transferred to ICU Slow to recover from anaesthesia and transferred to ICU

40. Tachyarrhythmias – started on a metoprolol Tachyarrhythmias – started on a metoprolol Stabilized somewhat – transferred to CCU at PLC Stabilized somewhat – transferred to CCU at PLC Diagnosis of Sick Sinus Syndrome Diagnosis of Sick Sinus Syndrome No interventions regarding the intraparenchymal bleeds No interventions regarding the intraparenchymal bleeds

41. One more thing Anchoring Anchoring Start with an anchor – something you know – and adjust in the direction you think is appropriate Start with an anchor – something you know – and adjust in the direction you think is appropriate Often not enough adjusting Often not enough adjusting