Case: Roger “Roger” Rogers
You are back in the department at ABEM General Hospital when Emergency Medical Services (EMS) arrives with a patient.
Roger Rogers, 22 year old college football player was brought after “passing out” before a Saturday afternoon football game.
Initial vital signs: Blood pressure 110/70 Heart rate 141 Temp 98.9F
Respiratory rate 14 Oxygen saturation of 99% on room air
You may begin the case.
Candidate: “What do I observe when I walk into the room?”
You see a smiling, well developed young man in full football uniform and pads, sitting up on the side of the gurney swinging his legs. He is surrounded by several fawning cheerleaders, EMTs, college athletic staff and his Mother.
Candidate: Ask EMS to stay. Introduction – “I am Doctor Candidate. How can I help you today?”
“Hi Doc! You have to let me go as soon as possible, this is crazy. Tonight is the ABEM Rose Bowl, and I am the star quarterback for ABEMU. I just fainted. It’s happened before. It’s really no big deal! Maybe it was just something I ate. Can I go?”
Candidate: Convince Roger to stay. (His mother will ally with you.)
I. STABILIZE
CA: ABC’s: IV access (normal saline at a to keep open rate), O2 6L by nasal cannula, cardiac monitor, pulse oximetry, EKG, portable chest X-ray
Finger stick glucose 99
Cardiac rhythm strip: HR 190 wide (QRS = 140ms) and regular
IA: Ascertain if Roger is stable or not stable. (He has no chest pain, alteration of mental status, hypotension, or sign of shock).
Repeat vital signs are BP 120/80 HR 185 RR 12 sat 100% on 2L O2
Patient is well perfused, alert/oriented, and without complaints.
IA: Place pacer pads.
II. BRIEF HISTORY AND ESSENCE PHYSICAL
Roger says he fainted during the pre-game pep talk. He sustained no trauma. No has no pain. He says that he “feels pumped”. He denies all symptoms.
Undress the patient. Pulses are strong, tachy and equal bilaterally. Skin is moist and warm. Normal breath sounds. PMI is not displaced. No bruits. Pupils are equal 6mm round and reactive. Cervical spine is non-tender to palpation. Patient is hyperactive, hyperkinetic, and seems euphoric.
III. INITIAL STUDIES
CBC, chemistry with Ca/Mg/Phos, cardiac enzymes are pending
Chest x-ray(CXR) is normal, no left ventricular hypertrophy(LVH)
EKG has wide, regular ventricular tachycardia with no obvious injury pattern
UA dip is normal. Toxicology pending
Orthostatic vital signs are within normal
After the EKG is shown to the candidate, Roger insists on leaving.
“Look Doc, you have listened to my chest, stuck me for blood, taken my urine and now you have even seen an EKG. I demand you release me. I am pre-law and I know that you have to let me go if I am willing to sign out against medical advice (AMA). I have to get back to the most important game of my life!”
IV. INITIAL TREAMENTS
Candidate: Convince Roger to stay. Explain that you want to order IV medicine (Amiodarone 150mg over 10 minutes IV) to slow his heart rate, which is in a dangerous type of rhythm that could degenerate to a fatal one.
Roger whispers conspiratorially to you, “Listen doc, I know why your heart test looks funny. Maybe I did something I am not supposed to. But I sure as heck can’t tell you things that would show up in my medical records!”
CA: Give benzodiazepine for sympathomimetic induced tachydysrythmia (Ativan 1-2mg IV).
Repeat vitals 120/70 99 14 100% 98.0
Roger says he feels calmer. (“Doc – you stole my mojo!”)
V. COMPLETE HISTORY AND PHYSICAL
Complete history
Allergies NKDA
IA: Meds none
IA: Past syncopal episodes x5 during exertion.
Last tetanus when he got stitches after fainting while riding a skateboard and lacerating his chin 2 years ago. Last ate lunch 3 hrs ago.
Events – tonight is the big game, temperate fall afternoon.
IA: Family history of two cousins died of “heart attacks” in late teens and twenties
Records none.
Immune unknown
EMTs say the patient was in the pre-game pep talk in the locker room with his arms around the other players, yelling and screaming in anticipation, when he was witnessed to gasp and loose consciousness. He was immediately caught by six other players and the coach with no trauma sustained. No seizure activity or cyanosis. Loss of consciousness was for less than 1 minute. No postictal period. Normal finger stick glucose in the field. No complaints. Patient refused C-collar and board per EMS.
IA: Narcotics – if asked sniffs “a pick me up” only before games. Does not know what it is (“Speed or something”), given to him by a one of the Board of Trustees of the University and a team athletic booster. No steroids.
Doctor – none; has seem university counselor several times to discuss long history of frightening nightmares
Social – college athlete bound for the NFL next season; single; no tobacco or alcohol
Complete physical
GEN – mildly agitated
SKIN – warm, no lesions, moist
HEENT – white powder in bilateral nares
NECK – no goiter, bruit
CHEST – no murmur, gallop, rub, thrill. Normal PMI
BACK – normal
ABD – normal, RECTAL/GU – normal
EXTREMITIES – normal
NEURO – brisk deep tendor reflexes, mild tremor
VASC – normal
VI. DIFFERENTIAL DIAGNOSIS
Includes but is not limited to: Toxidrome, tachydysrythmia, substance abuse, hypertrophic cardiomyopathy, aortic stenosis, seizure, pulmonary embolus, neurocardiogenic syncope, endocrine disorder, mood disorder
VII. CONFIRMATORY TESTS
Urine toxicology returns + cocaine
CA: Repeat EKG (at lower heart rate) shows saddle-shaped, coved ST segments V1-3
ECHO – normal
Roger’s head coach arrives in the Department and shouts at Roger to come with him back to the stadium. Roger begins arguing loudly with his mother, because she wants him to stay in the ER. She remembers her sisters’ sons who as young men “Passed with heart attacks”. Tempers flare. Roger gets very agitated and collapses onto the floor.
CA: Protect cervical-spine and begins ABC’s.
Roger is unconscious but has a pulse. Ventricular tach is on monitor at a rate of 240 BPM.
CA: Attempt immediate synchronized cardioversion at 100J
Roger is unconscious. He has no pulse. Asystole is on the monitor.
CA: Immediately start CPR.
While preparing to endotrachealy intubate and drawing-up epinephrine and atropine, Roger opens his eyes and shouts “Hey, stop pushing on my chest!”
Rhythm strip shows ventricular tachycardia HR 130. Pulses are equal and regular. Breath sounds are normal. Trachea is midline. Respiratory rate is normal. No tympany on percussion of the chest. Roger now has some sternal, reproducible anterior chest pain, and bruising and crepitus over the sternum. No signs of shock.
CA: Rate control stable ventricular tachycardia. Give amiodarone 150mg IV over 10 minutes.
Repeat vital signs. BP 110/60 HR 101 Temp 98.6 RR 12 100%
“Hey doc, my chest is killing me.”
IA: Treat post-compression sternal chest pain with narcotics, order sternal x-rays.
Repeat vital signs. BP 110/60 HR 80 Temp 98.6 RR 12 100%
Normal sinus rhythm on the monitor.
Repeat EKG ordered.
Arterial blood gas (ABG) sent.
Sternal X-ray – fractured and overriding sternum
VIII. CONSULTS
IA: Consults trauma or cardiothoracic surgery for sternal fracture
CA: Admits to cardiology (discus AICD placement and further EP studies)
IA: Recognizes Brugada’s syndrome (SCN5A, which codes for a subunit of the cardiac sodium channel)
IX. FINAL TREATMENT AND STABLIZATION
IA: Amiodarone IV drip 1mg/min
IA: Make NPO, maintenance IV fluids
X. FINAL DISPOSITION
CA: Admits to CCU/ICU
IA: Candidate discusses disposition with patient and family
Roger’s uncle, the father of his two deceased cousins, arrives in the department and convinces him to be admitted to the hospital. Discus the Brugada’s syndrome and disposition with Roger and Mother. Mother thanks you and says, “I always thought there was something wrong with the men in this family.”
Dangerous actions:
Beta-blockers for cocaine toxicity (unopposed alpha activity)
Allowing him to sign out AMA
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