Sidebar: A Hasty Diagnosis

I was speaking with a nurse friend the other day about an experience she had while attending a NASCAR event with friends. She had a syncopal event, which prompted a call to 911 and an evaluation by paramedics.

Although she did not have any seizure activity (nor was it reported), the concern of the first responders was a grand mal seizure. She was subsequently evaluated in the emergency center with that "diagnosis" and discharged with recommendations for additional (and expensive) testing.

It didn't seem—although one shouldn't criticize if one wasn't there—that the common causes of syncope in that particular environment were considered in the rush to find the not-so-common (and yes, perhaps more serious) etiology. No IV was started nor was an ECG obtained. Ultimately, it was decided that the syncopal episode was likely secondary to volume depletion.

Now, I realize syncope is a transient abrupt loss of consciousness with complete return to preexisting neurologic function. Population-based studies have indicated that approximately 40% of adults have experienced syncope, with women being more likely than men to report an event. Neurally mediated syncope is the most common type, with cardiac syncope being the second.

I also realize that seizures and syncope are often confused. Features most suggestive of a seizure are tongue laceration, head turning, and witnessed abnormal posturing—none of which my friend had. Factors strongly predictive against seizure are presyncopal spells before loss of consciousness, diaphoresis before a spell, and loss of consciousness with prolonged standing or sitting.¹ Perhaps orthostatic syncope, in this case secondary to volume depletion, could have been explored (or at least treated) early on.  No doubt syncope in older persons generally has more than one etiology, making the diagnosis difficult and requiring additional information on medications, past history, level of cognitive impairment, and physical frailty.

REFERENCE
1. Gauer RL. Evaluation of syncope. Am Fam Physician. 2011;84(6):640-650.

I was speaking with a nurse friend the other day about an experience she had while attending a NASCAR event with friends. She had a syncopal event, which prompted a call to 911 and an evaluation by paramedics.

Although she did not have any seizure activity (nor was it reported), the concern of the first responders was a grand mal seizure. She was subsequently evaluated in the emergency center with that "diagnosis" and discharged with recommendations for additional (and expensive) testing.

It didn't seem—although one shouldn't criticize if one wasn't there—that the common causes of syncope in that particular environment were considered in the rush to find the not-so-common (and yes, perhaps more serious) etiology. No IV was started nor was an ECG obtained. Ultimately, it was decided that the syncopal episode was likely secondary to volume depletion.

Now, I realize syncope is a transient abrupt loss of consciousness with complete return to preexisting neurologic function. Population-based studies have indicated that approximately 40% of adults have experienced syncope, with women being more likely than men to report an event. Neurally mediated syncope is the most common type, with cardiac syncope being the second.

I also realize that seizures and syncope are often confused. Features most suggestive of a seizure are tongue laceration, head turning, and witnessed abnormal posturing—none of which my friend had. Factors strongly predictive against seizure are presyncopal spells before loss of consciousness, diaphoresis before a spell, and loss of consciousness with prolonged standing or sitting.¹ Perhaps orthostatic syncope, in this case secondary to volume depletion, could have been explored (or at least treated) early on.  No doubt syncope in older persons generally has more than one etiology, making the diagnosis difficult and requiring additional information on medications, past history, level of cognitive impairment, and physical frailty.

REFERENCE
1. Gauer RL. Evaluation of syncope. Am Fam Physician. 2011;84(6):640-650.

I was speaking with a nurse friend the other day about an experience she had while attending a NASCAR event with friends. She had a syncopal event, which prompted a call to 911 and an evaluation by paramedics.

Although she did not have any seizure activity (nor was it reported), the concern of the first responders was a grand mal seizure. She was subsequently evaluated in the emergency center with that "diagnosis" and discharged with recommendations for additional (and expensive) testing.

It didn't seem—although one shouldn't criticize if one wasn't there—that the common causes of syncope in that particular environment were considered in the rush to find the not-so-common (and yes, perhaps more serious) etiology. No IV was started nor was an ECG obtained. Ultimately, it was decided that the syncopal episode was likely secondary to volume depletion.

Now, I realize syncope is a transient abrupt loss of consciousness with complete return to preexisting neurologic function. Population-based studies have indicated that approximately 40% of adults have experienced syncope, with women being more likely than men to report an event. Neurally mediated syncope is the most common type, with cardiac syncope being the second.

I also realize that seizures and syncope are often confused. Features most suggestive of a seizure are tongue laceration, head turning, and witnessed abnormal posturing—none of which my friend had. Factors strongly predictive against seizure are presyncopal spells before loss of consciousness, diaphoresis before a spell, and loss of consciousness with prolonged standing or sitting.¹ Perhaps orthostatic syncope, in this case secondary to volume depletion, could have been explored (or at least treated) early on.  No doubt syncope in older persons generally has more than one etiology, making the diagnosis difficult and requiring additional information on medications, past history, level of cognitive impairment, and physical frailty.

REFERENCE
1. Gauer RL. Evaluation of syncope. Am Fam Physician. 2011;84(6):640-650.