Syncope is a temporary loss of consciousness resulting from decreased blood flow to the brain. While the idea is simple, the mechanics of syncope can be more complex.
Near syncope, another term EMS providers are likely to hear, is loosely defined as an episode of dizziness or weakness associated with the same temporary loss of blood to the brain.
Aside from the potential traumatic injury to his hip, the assessment of Mr. Stevens should focus on a potential cause of his near syncope. In this case, measuring a blood glucose (if within your scope of practice) would rule out potential complications of his diabetes.
Otherwise, evaluating possible cardiovascular causes should be high on the differential diagnosis list. In Mr. Stevens’ case, there are three clues indicating syncope of cardiovascular origin:
- Abrupt position change
- Poor oral intake
- Beta-blocker medication
Near syncope when standing
Mr. Stevens’ hypertension is treated with beta-blockers, which lower blood pressure by decreasing heart rate and contractility. These effects combine to decrease overall cardiac output. A recent illness with poor fluid intake can cause mild dehydration leaving less overall circulating volume in the body. Finally, a rapid change in posture — supine to standing — changes the demands on the body as it attempts to maintain homeostasis against gravity.
All three of these effects can combine to cause syncope or near syncope as seen with Mr. Stevens. When the patient stands quickly the body attempts to compensate by accelerating the heart rate; in this case, however, beta-blockers keep the heart rate artificially low and don’t allow for a rapid response to changing needs. Additionally, mild dehydration reduces preload and, along with bradycardia, reduces cardiac output. As gravity pulls blood from the brain the patient’s cardiac output is unable to compensate and cerebral perfusion is decreased to the point where syncope occurs. In Mr. Stevens’ case, this is also associated with a loss of muscle tone and a fall.
Positioning based on patient findings
A patient who has suffered a syncope related to a change in position may or may not be hypotensive when lying down. Symptoms may be exacerbated when moved from lying to sitting or standing and a thorough assessment should include evaluation of orthostatic vital signs. In Mr. Stevens’ case, however, a change in position to sitting or standing is not feasible because of his potential hip injury.
He may tolerate elevating his legs, however, into Trendelenburg position but is there any benefit to doing this? While this was traditionally taught to EMS providers as a way of “forcing” blood to the brain, a review of available peer-reviewed literature demonstrates that while more research is needed, Trendelenburg position “does not reveal beneficial or sustained changes in systolic blood pressure, preload, afterload, or cardiac output."[1]
At best, use of Trendelenburg is subject to competing expert opinions and while it has not been shown to broadly benefit patients it also has not been shown to cause harm. In Mr. Stevens’ case, his injured and painful hip contraindicates use of Trendelenburg.
Conclusion
Because Mr. Stevens’ weakness symptoms are absent went lying down and because his pain increases when sitting upright, you elect to leave him in a supine position. The paramedic from the ambulance starts an IV and gives the patient pain medication and fluid prior to moving him. Careful to keep him flat, you lift Mr. Stevens over to the stretcher and pad his affected leg to keep him comfortable. Mr. Stevens is transported to the emergency department without issue.
References
1. Bridges, N., & Jarquin-Valdivia, A. A. (2005). Use of the Trendelenburg Position as the resuscitation position: To T or not to T? American Journal of Critical Care,14(5), 364–368.
