Syncope … Or Is It ?

Hx: A male in his 80’s is transported by EMS after a cardiac arrest. His family called 911 after they heard him fall in the bathroom and found him unresponsive. The paramedics found the patient pulseless and apneic. ACLS protocols were initiated, he was intubated (without medication), CPR was given, and he had return of spontaneous circulation just prior to arrival in the ED after receiving IV epinephrine.

Past Medical Hx, Social Hx, and Meds are all unknown.

Exam:

  • Vital signs currently: BP 70/30, HR 55, Respirations assisted with bag, Intubated, sat 100%
  • HEENT: Forehead contusion, pupils fixed at 5mm bilaterally, endotracheal tube in place, no facial deformity
  • Resp: breath sounds equal bilaterally
  • Cardiovascular: poor pulses in all 4 extremities, heart sounds minimally audible
  • Abdomen: soft, non-distended, no pulsatile masses
  • Extremities: cool, pulses present but weak
  • Neurological: GCS 3, no response to painful stimuli, no spontaneous respirations, no gag reflex.

Differential:

  • Septic Shock
  • Ruptured AAA / Hemorrhagic Shock
  • ACS / AMI / Dysrhythmia
  • Medication Overdose / Interaction
  • Intracranial Hemorrhage
  • Electrolyte Abnormality / Renal Failure
  • Massive Pulmonary Embolism

ED Course:

  • Ongoing resuscitation of the patient is continued with IVF and initiation of pressors.
  • Chest xray – normal
  • EKG – bradycardia, sinus, rate 50
  • Initial labs show normal hemoglobin, normal platelets, and normal white blood cell count
  • CT head: normal
  • CT cervical spine- returns the following image:

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Fracture through the odontoid of C2 with near obliteration of the spinal canal at that level.


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Posterior displaced dens of C2 and body of C1

 

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Atlanto-axial distraction

Discussion:

This case demonstrates a severe cervical spine injury that resulted in immediate death. Although the rapid arrival and efforts of EMS resulted in return of spontaneous circulation for a brief period of time, the differential was focused on circulatory causes of shock and death. However, it is important to consider spinal shock as a result of spinal cord injury in the differential. The typical presentation of spinal cord injuries includes hypotension and bradycardia with neurological defects. In this case, the absence of any response, including respirations, was distracting as focus was placed on anoxic brain injury as the cause. In addition to the traditional search for syncope or sudden death, the elderly are at particular risk of this type of injury from falls due to cervical immobility and degenerative changes.

In this scenario, the injury is lethal. However, when injury is lower in the cervical cord or thoracic or lumbar spine, injuries are survivable. Keep in mind the bradycardia and hypotensive presentation of spinal cord injury.

 

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