You are assisting the instructors at the fire academy as they are running a group of recruits through basic drills. It is a pleasant day, not too hot, not too humid. The current evolution involves carrying a hose line up a staircase and has been going on for about 20 minutes.
From a small distance away you see a recruit come out of the tower and drop his equipment, and then promptly fall over to the ground. You arrive at his side in a few seconds and find that he is unconscious, but breathing.
Your EMS unit arrives and the recruit regains consciousness after about 5 minutes. His vitals are normal, and he states at first that he has no medical history and this has never happened before. He does not want to go to the hospital.
So what happened to him?
It's hard to say at this point, but he seems to have suffered a syncopal episode — he passed out. The technical definition of syncope is the transient loss of consciousness secondary to a brief decrease in cerebral blood flow that spontaneously and completely resolves with no resuscitation. Basically, one's brain does not get enough blood supply and thus, oxygen.
The concern is why did it happen, and could it happen again?
Syncope is a common condition we deal with in the emergency department. Approximately 3 percent of hospital emergency department visits are for syncope; however, the precise cause is only identified in no more than 50 percent.
There are a number of life-threatening causes that we need to consider. We need to consider them so we can convince patients to go to the hospital for further evaluation, and in some cases to determine if the patient needs to have an ALS workup and transport.
Here are four causes warranting special consideration.
Subarachnoid hemorrhage — bleeding in the brain
These patients will typically have a headache before or after the syncope, but not always. It may be associated with severe vomiting, or a neurological deficit — numbness or paralysis in one part of the body for example. This condition could occur during exertion.
Acute coronary syndrome and arrhythmia
In other words, a heart attack or an abnormal heart rhythm. While ACS usually presents with chest pain, it may be more subtle, and have only shortness of breath, weakness or syncope. The possibility of an abnormal heart rhythm is very concerning and is the cause of syncope in 20 percent of older adults.
There are several conditions that affect younger patients however, such as WPW or Brugada syndrome. The details of these conditions are out of the scope of this article, but they may be transient and not be seen on the EKG at the time EMS evaluates the patient. Some of these have a family history, and place the patient at risk of sudden cardiac death. These can also occur during exertion.
An aortic dissection in the chest or an abdominal aortic aneurysm can cause a sudden decrease in the blood flow to the brain, prompting the syncope. While we would expect these to be associated with pain or other symptoms, they need to be considered.
Ruptured ectopic pregnancy
For female patients, this is a concern until we can rule out pregnancy. An ectopic or tubal pregnancy is when the pregnancy implants in an area where it shouldn't such as the fallopian tube. This can result in the rupture of the tube as the baby grows.
Knowledge of these conditions helps guide our physical exam and history taking of the patient, and gives us ammunition to help convince the patient to go to the hospital.
Some syncopal episodes are less concerning. These include emotional fainting after upsetting news, in the setting of dehydration, or syncope that occurs when the patient stands up quickly. While it is still necessary for these patients to be evaluated at the emergency department, syncope associated with these conditions often does not have a life-threatening cause.
Conversely, syncope in an older patient, associated with chest or abdominal pain, or in the setting of physical exertion is more concerning, particularly for life-threatening heart arrhythmia. Family history of an abnormal heart rhythm or sudden cardiac death at a young age is even more worrisome.
Any patient that loses consciousness should be transported to a hospital for further evaluation. This does not mean they are going to need to be admitted — many younger patients with non-worrisome histories can have an initial evaluation and then be discharged for outpatient follow up.
However transportation should be recommended and they should be transported by an ALS provider until arrhythmia and other life-threatening causes can be ruled out.
Upon asking our recruit, he finally admits that he has passed out before while exercising, but has never followed up with a doctor about it. He admits he never told the occupational health physician who administered his pre-employment physical about those prior episodes, or the fact that his brother died at age 34 due to an unknown heart irregularity.
He was transported to the hospital and was scheduled to undergo advanced evaluation by a cardiologist.
Taking care of our own sometimes does not just mean rehab at a fire scene. It often involves prevention of conditions that could affect the health and wellness of a firefighter. Knowledge of these conditions can help us support our brothers and sisters and make sure they receive the proper work up and evaluation when something goes wrong with the health.