Near-syncope at church

[zzyzx]

I realize that there are a few other scenarios running this week, but I have to share this one with you. This was the most interesting call of a very eventful weekend, one where I ran an eclamptic seizure and a 35 y/o full arrest at a dentist office. I really dodged a bullet on this call due to two dumb mistakes that I made.

You get called to a church on Sunday morning for a syncope. You arrive to find a 55 y/o heavyset woman sitting in the choir pew. There’s a little bit of sweat on her brow, but she doesn’t appear to be in any distress.

“I was standing up and felt like I was gonna pass out, but I sat down on the floor before I did. I was too weak to get up by myself, but my friends helped me.”

History of dialysis. She goes Tuesday, Thursday, and Saturday. Only other history is hypertension, which was the cause of her kidney failure. (Sorry, but I forgot her meds.)

Her vitals are within normal limits. Lungs are clear and sats are normal. So is her blood sugar. Normal sinus on the monitor. (Sorry, but my system only uses obsolete 3-lead monitors.)

She is weak, but with assistance you are able to walk her down the three steps of the choir pew and onto your gurney.

What else you would you like to know? Treatments?

This won’t be to hard for you guys to figure out, but it’s a very interesting and, I think, educational scenario. By the way, my initial impression was that this was vaso-vagal (near) syncope. I was wrong.

[p3medic]

Too much Jesus....

[Just Plain Ruff]

I was thinking more of the heavy set woman at the church in Ray Stevens song about the squirrel getting loose in church.

[Christopher.Collins]

Did she go to her dialysis treatment on Saturday?

Hows her skin temp and appearance? Whats the temp like in the church?

Last meal and drink?

[zzyzx]

Xlnt question, Christopher! Major kudos!

That was one of my dumb mistakes. I was told her dialysis schedule, but did not immediately ask her when she last went. I found out much later that she had missed her last two appointments.

Her only complaint is generalized weakness. No chest pain, SOB, etc. She is in no distress, just tired.

[ericenglund]

Any time I come into contact with a renal patient, I ask when they last went to dialysis.

I've had a call very similar to this, 50something female at home, couldn't get out of bed due to weakness. Asked about hx. she stated renal failure and that she had missed her last 3 dialysis visits due to the busy holiday season. :shock:

Horrible looking ECG, gargantuan T waves.

Did you see peaked T waves on the 3 lead?

[letmesleep]

zzyzx, I'm curious, and not looking to break you down AT ALL, just wondering. You have stated here before that you don't have anything more than 3 lead capability. Do you ever do 9 leads with your monitor?

Again, just wondering!

[ERDoc]

I agree with previous posters. Vitals and EKG would be helpful in this case. As an aside, the two most dangerous places to be are church and standing on a corner minding your own business.

[zzyzx]

I don't do 9 leads with my 3-lead monitor because I don't believe that I would get the same diagnostic quality as using a monitor set up to do 12-leads.

I've used 12-lead monitors (Lifepak 12's) a lot in the past at my old service. We're supposed to be getting 12-leads sometime late this year.

[zzyzx]

Nope, no peaked T waves. While I was waiting at the ER, I looked down at the monitor and saw a BBB. I thought she had been in a normal sinus rhythm with no block before, but I wasn't sure if I remembered correctly. Her son came in and started asking her about her dialysis, and then I remember that I'd never asked her about when she'd last gone to dialysis. She wasn't very forthcoming, but it turned out she had not been since Tuesday. It was only at this point that I connected the dots and realized she was probably way hyperkalemic. I went searching for the charge nurse and told her, "Hey, I didn't realize this until just now, but she's missed two of her dialysis appointments, and she's in a bundle-branch block."

The ER was busy with a 2 y/o respiratory arrest that had come in just after our arrival. The charge nurse told me she'd get another nurse to come triage our patient, but he never came. We waited for a while longer, and now when I when I looked down at the monitor, her ECG basically just looked horrible. Our patient still had no complaint and was in no distress. I went looking for an ER tech so I could at least do a 12-lead (nearly everyone was in another room working on the 2 y/o), but fortunately at this time a nurse I get along with really well walked through the ER doors to start his swing shift. I showed him the strip and told him what was going on. All the beds were occupied, but he pulled one patient out of their bed and put him into a hall bed. He then got an order from the doc for 100 mg calcium before we even did the 12-lead. I did the 12-lead using the ER's machine, and it showed a BBB but only peaked T waves in two of the anterior leads. I wish I had taken a copy so I could post it. From what I understand, peaked T waves are more likely to show up at an early stage, while a BBB develops later.

Anyway, my patient had a good outcome, but she could easily have coded on our gurney. I felt stupid for not having immediately asked about her last dialysis and not immediately connecting the dots when I saw the BBB. I'll try to follow up with the nurse and let you know just how high her K+ ended up being.