A 21-year-old college student was brought to the emergency department by EMS following an episode of loss of consciousness on a hot summer afternoon. She is accompanied by her friends who witnessed the episode. She is awake and alert, and claims to be in her usual state of health now. She was in the cheer team and she lost consciousness just before the half time. She felt light-headed and weak prior to the episode with vague abdominal pain and nausea. She has no recollection after that and the next thing she can remember is that her friends were calling her name when she was lying on the floor. As per the friends, she looked pale initially and had shaky movements of the limbs for a few seconds. She was unconscious for less than a minute. After that her color returned and regained consciousness spontaneously. She was in her usual state of health until a few seconds prior to the episode. She never lost consciousness in the past. She has negative review of systems and takes oral contraceptive pills for birth control. Patient denies tobacco, alcohol, or illicit drug use. No significant family history. Vitals signs including orthostatic blood pressure are normal. Examination including neurological examination is unremarkable. EKG is normal. Urine pregnancy test is negative.
1. What is the diagnosis and next step of action?
Neurocardiogenic syncope. Discharge from the emergency department with patient education and precautions to take if she suffers another episode.
Patient in this case description is a young college student cheering for her team on a hot summer day. She had the warning signs with presyncopal symptoms, but she remained up on her feet that led to an episode of brief loss of consciousness followed by rapid spontaneous recovery. This is a classical description for neurocardiogenic syncope, also known as vasovagal syncope. It is not uncommon to have a few shakes during the syncope, usually less than 15 seconds. It is not a seizure as the episode was not long enough and she did not have postictal phase. Neurocardiogenic syncope is the most common type and carries a good prognosis. Description of the episode is diagnostic, and there is role for further investigation. Reassure and educate the patient on syncope and precautions to take to prevent recurrence. “Always position an unconscious patient in a recovery position, and never make him or her sit in the chair or hold him or her in upright position” as this will not help improve the circulation and regain consciousness.
Syncope is a sudden transient loss of consciousness with loss of postural tone and complete spontaneous recovery. It is a result of transient global cerebral hypoperfusion (Figure 41-1).