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Please HELP - case study

Posted

Specializes in CCU, MICU, Tele, L&D.

Not ur normal post! In hopes that maybe some of you will have information to help with this patient. There is not much written about the subject... and I am dying to get your thoughts on what might be going on with this patient. Physicians are not able to give much information on what might be going on with the patient or prognosis.

Case Study

First diagnosis - Neurocardiogenic-syncope

Hypotension

Bradycardia

26 yr old male with episodes of syncope. Over the last few years the syncope episodes have become more frequent. Patient is always pallor with fatigue.

Tilt table test was positive - 6 min into the test, patient went "asystole" x30 sec.

Patient had pacemaker placement. 1 mo later patient is still having episodes of pre-syncope and a heart drop >256x's. Patient is unable to have intercourse with wife.

Stress test duration lasted 7 min.

Echo - normal

EKG- normal

Lab values - normal

Dinith88

Specializes in CCU/CVU/ICU. Has 15 years experience.

Patient had pacemaker placement. 1 mo later patient is still having episodes of pre-syncope and a heart drop >256x's. Patient is unable to have intercourse with wife.

I'm not sure what is meant by 'heart drop'. If you mean his heart-rate slowed enough to cause symptoms then his pacemaker either A) needs to have the pacer/low-rate readjusted or 2)the pacemaker isn't working??? (has he had it checked??)

'Pre-Syncope' is kind-of a vague symptom/complaint where the patient feels like he/she's about to pass out. Could-be a WHOLE LOT of reasons for this...not soley bradycardia.

I'm doubting it's related to his heart-rate because i'm seriously doubting such a new pace-maker would be malfunctioning (has he had it checked??). Also, an episode of hypotension isnt always related to or caused by bradycardia.

Anyway, in a nutshell i guess i dont have an answer for you...

And if they guy is unable to get a boner there's a good chance it has nothing to do with his pre-syncope. (unless of course he's passing out just prior to getting a boner...in which case he may just be suffering stage-fright).

Christian_SN, RN

Specializes in CCU, MICU, Tele, L&D.

I'm not sure what is meant by 'heart drop'. If you mean his heart-rate slowed enough to cause symptoms then his pacemaker either A) needs to have the pacer/low-rate readjusted or 2)the pacemaker isn't working??? (has he had it checked??)

'Pre-Syncope' is kind-of a vague symptom/complaint where the patient feels like he/she's about to pass out. Could-be a WHOLE LOT of reasons for this...not soley bradycardia.

I'm doubting it's related to his heart-rate because i'm seriously doubting such a new pace-maker would be malfunctioning (has he had it checked??). Also, an episode of hypotension isnt always related to or caused by bradycardia.

Anyway, in a nutshell i guess i dont have an answer for you...

And if they guy is unable to get a boner there's a good chance it has nothing to do with his pre-syncope. (unless of course he's passing out just prior to getting a boner...in which case he may just be suffering stage-fright).

heart rate drop - pacemaker is set to work when the heart starts to drop at a fast rate... 15 beats (or somthing like that... this is new to me) like when a syncope episode is about to or is happening.

the pacemaker is working great but syncope episodes are still occuring.

pre-syncope , u had right on... is a dizziness - a feeling of almost passing out.

bonner is not the issue, rather pre-syncope and chest pain during/after climax.

any add. help you have would be great. thanks

this patient has a lot of nurses and physicians wondering what is going on... ekg are fine. i of course do not know what to make of the heart (?) problem.

begalli

Specializes in Critical Care/ICU.

Has he been checked for hypoadrenalism? Some of the s/s of this are syncope. fatigue, low bp, low hr.

I don't know much about hypoadrenalism and the only reason I suggest this is because my daughter was having the opposite problem. She's 26, was having hypertension, tachycardia, was always on edge like she would have a panic attack. After ruling out a dozen other problems they had her collect a 24 hr urine for pheochromocytoma - a condition of the adrenal glands.

Probably a shot in the dark, but you never know.

gizelda196

Specializes in critical care. Has 15 years experience.

Have they interogated the pacer? Has he been cathed?

Dinith88

Specializes in CCU/CVU/ICU. Has 15 years experience.

Pacemakers work in whole lotta different ways. You'll learn more about pacemeakers when you're out of school and if/when you start dealing with them. Simply put, the PM 'watches' (senses) your heart rate and when it falls to a certain rate (50-60-70 usually, but can be higher or lower) it then 'paces' your heart to ensure the rate doesnt fall below the pre-determined threshold. But it has no way of knowing that a syncopal episode is about to occur (yet! Give it a few years :) )

If PM is 'working great' then forget about the whole bradycardia thing, as it's obviously not the culprit at this point.

If, as you say, syncope is still occuring then this person needs to stop driving, etc. until a proper diagnosis/treatment can be had.

Hypotension is still a potential (and until proven otherwise the primary) cause of this pre-syncope/syncope.

'Neurocardiogenic syncope' is a fancy way to say someone is vagaling. (look into vasovagal response/syncope). People 'vagal out' for lots of reasons (pain, surprise, fear, stress, etc.) and some unlucky people have 'hyper-sensitive' vagus-nerves. This could very well be the case here. Although the PM is protecting against symptomatic bradycardia, it wont help with the vasodilitation associated with a 'vagal response'.

Now, the whole chest-pain with sex is troubling and needs adressing (someone mentioned angiogram). I'm sure with all these troubled doctors puzzling over this case that at least one has considered this...

There is a syndrome called Shy-Draeger's that is a progressive neurologic disorder that keeps the vessels from vasoconstricting in response to activity, etc, and often will present with syncope, low BP, etc. Usually diagnosed by neurology, but I thought it usually was older people.

has your team considered a vagal nerve stimulator?

Christian_SN, RN

Specializes in CCU, MICU, Tele, L&D.

Has he been checked for hypoadrenalism? Some of the s/s of this are syncope. fatigue, low bp, low hr.

I don't know much about hypoadrenalism and the only reason I suggest this is because my daughter was having the opposite problem. She's 26, was having hypertension, tachycardia, was always on edge like she would have a panic attack. After ruling out a dozen other problems they had her collect a 24 hr urine for pheochromocytoma - a condition of the adrenal glands.

Probably a shot in the dark, but you never know.

thanks for the reply. i wrote hypoadrenalism down to look into... like his labs and ect...

thanks for your help

Christian_SN, RN

Specializes in CCU, MICU, Tele, L&D.

Have they interogated the pacer? Has he been cathed?

yes inspections (interogated?) have been done.

no cath has been done....

very ekg looked fine,,, :uhoh21: ...

he did have absent P wave after pacement of pm which is back now.

i hope that i did answer ur question... i am learning... doing my best.

thanks for you reply and care

Christian_SN, RN

Specializes in CCU, MICU, Tele, L&D.

Pacemakers work in whole lotta different ways. You'll learn more about pacemeakers when you're out of school and if/when you start dealing with them. Simply put, the PM 'watches' (senses) your heart rate and when it falls to a certain rate (50-60-70 usually, but can be higher or lower) it then 'paces' your heart to ensure the rate doesnt fall below the pre-determined threshold. But it has no way of knowing that a syncopal episode is about to occur (yet! Give it a few years :) )

If PM is 'working great' then forget about the whole bradycardia thing, as it's obviously not the culprit at this point.

If, as you say, syncope is still occuring then this person needs to stop driving, etc. until a proper diagnosis/treatment can be had.

Hypotension is still a potential (and until proven otherwise the primary) cause of this pre-syncope/syncope.

'Neurocardiogenic syncope' is a fancy way to say someone is vagaling. (look into vasovagal response/syncope). People 'vagal out' for lots of reasons (pain, surprise, fear, stress, etc.) and some unlucky people have 'hyper-sensitive' vagus-nerves. This could very well be the case here. Although the PM is protecting against symptomatic bradycardia, it wont help with the vasodilitation associated with a 'vagal response'.

Now, the whole chest-pain with sex is troubling and needs adressing (someone mentioned angiogram). I'm sure with all these troubled doctors puzzling over this case that at least one has considered this...

All I really know which is not much is... the PM detects if his heart rate falls at a fast pace (15 beats) then kicks hr up to 90 for 1 min. His lower rate is set at 60 bpm. I only said that so I can learn if I do have this right? And to learn more from ur replies.

Bradycardia is not a problem b/c PM has a set rate at 60 bpm..... Right?

Not that I am stereo type... but he is a male... very much a white coat syndrome. Just getting him to tell us what is going on is a big challenge (the wife gives most/all the information). I do not know if he is driving all the time, but after every discharge -he is at work the next day. -I think there is some denial of his problems. :uhoh3:

Hypotension makes a lot of sense, now. I did not know if it was the heart causing the syncope or vagal response causing the heart. It is very difficult to understand what causes what, I have researched but to no avail.

'Neurocardiogenic syncope' diagnosis is not a great diagnosis to me, call me crazy. I feel with his symptoms then it must be heart.? I thought if it was heart it could be the ONLY thing that could explain the *astyloic >5 sec (which he had 30 sec) on the table test? I thought I read that in my research, is this right?

So he would need an angiogram? He is scheduled for a stress test on tues.

Christian_SN, RN

Specializes in CCU, MICU, Tele, L&D.

There is a syndrome called Shy-Draeger's that is a progressive neurologic disorder that keeps the vessels from vasoconstricting in response to activity, etc, and often will present with syncope, low BP, etc. Usually diagnosed by neurology, but I thought it usually was older people.

thanks, i'll look into that... thanks again

Dinith88

Specializes in CCU/CVU/ICU. Has 15 years experience.

I thought if it was heart it could be the ONLY thing that could explain the *astyloic >5 sec (which he had 30 sec) on the table test? I thought I read that in my research, is this right?

So he would need an angiogram? He is scheduled for a stress test on tues.

Yes his heart was 'stopping' (pausing) for 30 seconds...however, it could be from various reasons. When someone 'vagals', the vagus nerve is responsible for inducing this pause (thus the 'neurogenic' origin). Ischemia is another possible cause (thus the coming stress-test/possible angio.) because if you're denying blood-flow to certain areas of your heart (ie. AV-node, etc) an asystolic event could happen (certainly a possibility given his chest pain). There're other possible causes of syncope (ie tight carotids, tia's, epilepsy, etc.) but if he's failed a tilt-test (had a 30 second pause) then the docs are obviously on the right track.

From what you've given us, it sounds as though the poor fellow is vagaling. And this guy may be in denial, but if he passes out at the wheel and kills innocent people he'll have even bigger problems. Someone needs to remind him of this...

Christian_SN, RN

Specializes in CCU, MICU, Tele, L&D.

Yes his heart was 'stopping' (pausing) for 30 seconds...however, it could be from various reasons. When someone 'vagals', the vagus nerve is responsible for inducing this pause (thus the 'neurogenic' origin). Ischemia is another possible cause (thus the coming stress-test/possible angio.) because if you're denying blood-flow to certain areas of your heart (ie. AV-node, etc) an asystolic event could happen (certainly a possibility given his chest pain). There're other possible causes of syncope (ie tight carotids, tia's, epilepsy, etc.) but if he's failed a tilt-test (had a 30 second pause) then the docs are obviously on the right track.

From what you've given us, it sounds as though the poor fellow is vagaling. And this guy may be in denial, but if he passes out at the wheel and kills innocent people he'll have even bigger problems. Someone needs to remind him of this...

WOW - the 'ischemia'... never knew. he has great physicians (he has the best in the area), just needed more information and the diagnosis seem more like a weak diagonosis to me.

still learning and will every day in this life. thank you so much for your time and knowledge.

the next time i see the patient, i will let him know the do's and don't's of his condition (i just do not want to over-ride the RN - i'll talk with her about how we can approach it together with him),,, there's an idea.

thanks, jen.

Christian_SN, RN

Specializes in CCU, MICU, Tele, L&D.

patient had stress test with no st slope decellerations, just a passing out episode.

dianah, ADN

Specializes in Cath Lab/Radiology. Has 46 years experience.

Did the MDs decide the PVCs are what are causing the sycope/passing out spells?? Are they isolated PVCs (which most ppl have) or did they come in bursts or groups, and are they directly the cause of the passing out? Has an EP study or ICD implantation been considered? Just curious . . .

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