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C. García Mauriño*, A. Molina García**
*Post-doc research fellowship en el Centre for Vaccines and Inmunity, Research Institute del Nationwide Childrens Hospital, Columbus, Ohio. **Adjunta de los Servicios de Urgencias y Unidad de Cuidados Intensivos Pediátricos del Hospital Nisa Pardo de Aravaca (Madrid)
9. Syncope in the emergency department
Doctor: Hello, the nurses have told me that Emma has passed out this morning, is that right?
Father: Hello Doctor. Yes, it happened in school during her P.E class today. I wasn’t there but the teacher explained what happened.
Doctor: How old are you Emma? Were you doing some type of physical activity before you lost consciousness? How long was she in this situation?
Emma: I’m 14 years old and we were lying down on the floor doing push ups. I stood up when I finished, and a few seconds later I felt dizzy and that is the only thing I can remember. When I woke up my teacher was standing beside me and I didn’t understand what had happened.
Father: The teacher told me that she fell to the floor, after a few seconds she started to move her extremities violently but briefly, and after that she woke up normally as if nothing had happened.
Doctor: Emma, did you feel anything else before fainting? Nausea, difficulty to talk or move certain parts of your body, sweaty? Double or blurry vision?
Emma: Neither of those things, I felt perfectly OK before and after this happened. I just felt the dizzyness I told you about before.
Doctor: During the episode, did she loose her postural tone? Did she wake up spontaneously? After she woke up was she confused or did she had a normal behaviour? Did she vomit in these past hours? Has she had fever or flu symptoms during these past days?
Father: Yes, the teacher said she lost her tone but she woke up perfectly fine afterwards. She has even eaten after the incident because she was hungry.
Doctor: Does she or any other member of the family have any chronic illnesses, especially heart diseases? Has something similar ever happened before?
Father: No, she is perfectly healthy. This is the first time she has felt dizzy or has lost consciousness.
Doctor: What you are describing seems to be a syncope. This is a bening process which consists of a sudden loss of consciousness and muscle tone caused by cerebral hypoperfusion or inadequate oxygen or glucose reaching the brain. There are many causes for this situation, from a cardiac or respiratory origin to a metabolic or vasovagal one. The most common causes are vasovagal and orthostatic hypotension, but we have to rule out the rest of the possibilities. We are first going to measure her blood glucose levels, determine her blood pressure lying down and standing up and examine her, and do an electrocardiogram to see how her heart works. If everything is normal she can go home.
Father: Can she do her normal life activities? Does she need medication? Can this episode happen again? Is there anything we can do?
Doctor: If all the results come back normal and we are dealing with an orthostatic syncope, which is the most probable cause taking into account it happened when she suddenly stood up, she shouln´t need any medication. She can do her normal activities. However these episodes can recur and because of this, it would be good she learns to identify what we call the premonitory symptoms, or the changes she feels before passing out like the dizzinies. When these happen she should lie down slowly and elevate her legs or sit down with her head between her legs in order to improve the venous return to the brain.
KEY WORDS:
Syncope: síncope.
Passed out: desmayarse.
P.E classes: physical education classes.
Dizzy: mareado.
Double vision: visión doble.
Blurry vision: visión borrosa.
Fainting (To faint): desmayarse.
Postural tone: tono postural.
Flu symptoms: síntomas catarrales.
Chronic illnesses: enfermedades crónicas.
Heart diseases: enfermedades cardiacas.
Bening process: proceso benigno.
Muscle tone: tono muscular.
Cerebral hypoperfusion: hipoperfusión cerebral.
Orthostatic hypotension: hipotensión ortostática.
Rule out: descartar.
Blood pressure: tensión arterial.
Electrocardiogram: electrocardiograma.
Recur (to recur): repetirse.
Premonitory symptoms: síntomas premonitorios.
Venous return: retorno venoso.
