WHAT you GUNNA DO if your PATIENT PASSES OUT ON YOU?

February 8, 20140 Comments
Fainting_11254

Help I’ve fallen and I can’t wake up!

There’s no shortage of books that will enlighten you on what to do if your patient faints, loses consciousness, passes out or whatever you wish to call it, as you are performing your usual expert acupuncture job. But how accurate are these articles, who wrote them and what are their qualifications? It’s pretty easy for someone, even a professor, to say do this when you encounter an unconscious patient. Often with a good poker face your teacher, acting like an expert with years of clinical experience, will guide you. The only problem is most have no real world experience in dealing with this problem and therefore have some odd suggestions on how to approach it. I certainly know that to be true of at least one very successful book “generator,” in TCM. Plenty of “steam” no real locomotion.

Or you could consult a source that, by default, must know how to deal with loss of consciousness (LOC) in a patient. There’s a few to pick from in the medical profession for sure. But one in particular stands out. That would be the anesthesiologist because they deal with oblivion and all of the consequences that surround an obtunded patient. Anesthesia is the science of unconsciousness. We get paid not for putting you to sleep, but to wake you back up-intact.

As an anesthesiologist with a master’s degree in TCM I can help bridge the gap between your understanding of biomedicine and modern medical protocol. I’ve seen thousands of patients “out cold” and all that can happen to them including heart attacks, strokes, hemorrhage and so on. Let me make it real easy for you if and when you encounter a LOC. Simply follow the protocol below:

  1. Recognize the problem.
  2. What to do when you encounter a LOC.
  3. What not to do when you encounter a LOC.

I’ll skip the “how to” of the ABC’s of which you all should be familiar with from your required CPR training and go ahead to a few things you’ll want to do.

First before you can hope to differentiate between a simple vasovagal response and let’s say severe dehydration or hemorrhage you’ll need a set of accurate vitals. Funny how it always comes back to those pesky vitals. Just like in our last blog how it would have made an enormous difference if someone had simply obtained a set of vitals to help rule out a pneumothorax. You probably thought you were finally done with them after PE class! But alas gentle reader, do not be so fast in their dismissal. Before we proceed this would be a great time to sell you a nice, accurate, blood pressure and pulse monitor but I don’t do that sort of thing. I can however, recommend that you pick one up. Someday you’ll thank me should you ever encounter an emergency.

As far as these devices go, pay a little extra for a good quality machine. A $100 or more should do it. The arm monitors are industry standard but I recently used a wrist device and found it pretty accurate. My concern is that with very low BP’s the wrist monitor may miss the pulse and prove inaccurate just when you needed it most. Omron makes anesthesia machines which have built in BP and heart monitors. They have a line of BP machines which are good. I own the one shown here.

cardiologyBP791-WEB-02092011_png_405x235_q85-382x220Why get a monitor? Well, if you truly have a Red Flag you’ll want to streamline things. While you are supporting the airway by chin tilt or jaw lifting, the monitor can be cycling and in a few moments produce not just a blood pressure but a pulse as well. Within less than two minutes you have all three vitals BP, HR and RR (sorry you have to read this one on your own). No urgent need for temp usually. Lastly, in anesthesia, our most useful toy is the pulse oximeter. An oximeter will instantly tell you the percent of oxygenated hemoglobin in your patient’s blood. It’s beyond the scope of my blog to discuss the applications but they are super useful (another blog?). The cool thing is that rather than hemorrhaging $5,000 on a Nellcor operating room device, you can buy one for as little as $89. These also give you a pulse rate. Normal, healthy people run about 98% saturated at sea level on room air. For example, let’s say you encounter a 25 yo female with c/o chest pain made worse with deep breathing and SOB. Her Hx: smoker, on birth control, just completed a long air flight. You get vitals which are all normal. Then you check the oximeter and it reads 85% on room air. Oh my gosh! That’s a pulmonary embolism until proven otherwise. See how useful a little gadget like that can be? BTW that was a true story.

Perhaps the coolest gadget ever!

The diminutive pulse oximiter. Fits over the finger and gives this nice LED readout. I’m buying one. Perhaps the coolest gadget ever!

Wrist device. About $60

Wrist device. About $60

You will want to have a working differential diagnosis for LOC based on the principle that common things happen commonly.

 

THE VASOVAGAL EPISODE

So the very first consideration is a vagal response. In an acupuncture setting this is by far the most common cause of fainting and in all likelihood it will be the reason why your patient lost consciousness IN 99 OUT OF 100 CASES. Here you usually have a nervous patient who is receiving acupuncture for the first time. Keep a heads up on these folks. Likewise, some sensitive people may swoon before you even start needling. Just make sure they are lying down before anything else. Otherwise catching someone can be pretty challenging. Should a LOC occur your vitals will show hypotension (systolic under 90 torr) with severe bradycardia (anywhere from the 50’s to mid 30’s). That’s if you obtain your vitals very quickly, before recovery. Within minutes BP will return to normal as will HR. What happens is these people enter the office with a fair amount of anxiety. Their fight or flight mechanism is activated to some degree. Upon the actual procedure of being needled there is a precipitous discharge of anxiety with a robust firing of the vagus nerve (parasympathetics) followed by a profound slowing of the heart rate and a subsequent dumping of blood pressure and LOC.

If this were due to severe loss of blood or dehydration for example from the stomach flu, the patient will show tachycardia (HR>100 BPM) and hypotension. You will also see dry mucus membranes and skin tenting. If due to internal  hemorrhage patient MAY have signs of Blood Xu but will always have a suggestive history for example a long history of ETOH abuse, NSAID’s, blood thinners or corticosteroid use. (Yes, another blog)

THE MECHANISM

Now back to the vasovagal discussion. Why do you black out when HR slows down? At some point the patient’s mean arterial blood pressure (MAP) will no longer be adequate to perfuse the brain. The brain can autoregulate blood flow up until MAP drops below about 60 according to some texts. At Norris Cancer Hospital, part of the USC Medical complex, we routinely dropped MAP’s to 50 torr without any problems. Which turns out to be an amazingly low BP of less than 70 torr systolic. However, for the upright (standing) patient they will pass out at higher MAP’s. Recall the equation:

Cardiac output (CO) = stroke volume (SV) x heart rate (HR).

SV is the quantity of blood ejected per beat. If SV were to remain the same and HR dropped significantly you can clearly see how CO also drops. Subsequently, the patient swoons, and if in the field, ends up horizontal and hopefully none the worse for wear. The new position is advantageous for several reasons which I won’t get into here but it puts the heart on an equal plane with the brain and is usually enough to reperfuse it and reestablish consciousness.

Most importantly look for the bradycardia. That’s the hallmark. Other signs will be sweating, pale complexion, and some mild twitching/jerking of limbs as they wake up. There will be no loss of bowel or bladder function in this scenario.

DO NOT CONFUSE THE LIMB TWITCHING FROM A VAGAL EPISODE WITH THE TONIC-CLONIC MOVEMENTS OF A SEIZURE.

TONIC CLONIC

TONIC CLONIC

They will also fully wake up and recover. They will not be groggy (post-ictal).

What to do after you obtain vitals. Remove all needles, after you get your vital signs or while the cuff is cycling. It’s a psychological response to an intended threat-like playing possum (yes, it’s true). It matters little if the needles remain in for a few more seconds after the patient is out cold. But it’s critical to assess vital signs as soon as possible to avert a catastrophe. Keep the cuff on and cycling as long as there is a threat. If you need to you can always put one leg up to your shoulders and allow it to drain for a minute then alternate with the other leg while the first one is now up with knees bent. This donates 300-400 cc of blood centrally per leg in an adult male and can quickly help boost blood pressure back to normal. You can try some resuscitation needling, or not. Either way this passes very quickly if it’s vasovagal. Should you find your patient on the floor put his or her legs up against the wall for up to 5 min. if possible.

WHAT NOT TO DO

Do not mistake a generalized seizure or massive heart attack for simple fainting. That is to say DO NOT exhibit closure and assume that it’s vasovagal and miss a true emergency. IN A MEDICAL EMERGENCY IT’S BEST TO NEVER ASSUME ANYTHING. Seizure activity which starts in both hemispheres or migrates into both produces LOC. Here however, one usually sees rhythmic contractions of the limbs or the classic tonic-clonic movements of a generalized seizure. An aura (visual or auditory) may be reported to you prior to the actual seizure. Look for any ID which may help you determine if they have a seizure disorder after things settle down. Patient will be post-ictal (drowsy and disoriented) from a true generalized seizure. As far as seizures themselves go there is not much you can do beyond making sure the patient does not fall off the table or if on the floor bang her head too hard. Fortunately, most seizures end very quickly and they can ventilate on their own through the activity. If you find that your patient is turning blue and is still seizing know that this is very common. Without IV access to stop the seizure there is little that you can offer them other than dialing 911 should you find the seizure continuing for more than several minutes. Should one continue for 30 min or more it’s called status epilepticus, a true medical emergency. Fortunately, it’s a rare event. Offer oxygen if it’s available but you cannot ventilate (remove CO2) a seizing patient under these conditions. It’s tough enough in the operating room to accomplish this so do not feel bad. Most seizures are self limiting. You do not generally need to call an ambulance either if you see that they have an ID which mentions a seizure disorder and they appear to be recovering without incident. Offer supportive care and call a family member for a lift home when they feel better. At my old TCM school a few years ago we had a case where this happened. I was notified but before I could say Jiminy Cricket however an ambulance had already been called. It is not necessary so hold off unless there is a better reason for it such as status epilepticus.

Do not miss a heart attack. It is beyond the scope of this article to detail the features of an acute coronary syndrome (perhaps the next blog) except to say that the presentation can vary depending on the gender, age and morbidity (diabetes?). Classic cardiac pain is most common in men. Consisting of crushing, squeezing, substernal, chest pain radiating down the left arm and up into the left jaw. There is shortness of breath, sweating (activation of fight or flight), and a sense of dread called angor animi.

Should your patient collapse without any signs or symptoms, and is nowhere near a needle or needle threat call 911, ABC’s, get vitals going while you look to the history (in chart) for clues which may be very important for the paramedics to know: past medical history, age, smoker, family history of heart disease, body habitus, male or female? Give paramedics all the information you have gleaned. The ride from the “field” to the big house is a culling point. Many patients die in the truck heading to the hospital. Any bit of history may be life saving.

Massive stroke and severe hypoglycemia are other common players. Both of these will often give fair warning with a dynamic change in mental status first. That is to say they will become disoriented prior to blacking out. Low blood sugar activates the fight or flight mechanism so you may see sweating, tachycardia and trembling.

hypoglycemiaxx

Bottom line is if your patient does not wake back up in five minutes max you may have a true catastrophic emergency on your hands. In that case it’s 911 time while you continue your ABC’s and assessing vitals. The great news is that it’s almost never anything more than a simple vagal response.

Incidentally, I am a personal expert on vagal reactions. On three occasions while I was pre-med I nearly fainted twice (both times in the operating room with my Dad) and went out cold once. The last case occurred when I was still in college at ASU. Long story short, after viewing the first 5 minutes of a knee operation I was out. Lucky for me Sandy, a big Olympic bobsled  competitor, was right behind me and caught me as I sailed reaching for the floor! A clinical pearl: this response is often times heralded by a big SIGH right before hitting the pavement. Be on the lookout if you see one of those in the right setting.

Filed in: Loss of consciousnessOFFICE EMERGENCIES
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About the Author ()

Christopher Rasmussen MD, MS is Founder and Professor at AdaptiveTCM where helps Traditional Chinese Medicine Practitioners treat complex patients with confidence through providing online CEUs and research. Dr. Rasmussen is currently writing a comprehensive, preventive medicine book, with an emphasis on inflammatory components of disease prevalent in today's patients.

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