A 67 y/o male has fallen to the ground at his residence. His “partner” called 911 after seeing that he was unconscious. Upon your arrival the patient is alert and requesting that you pick him up because he really needs to make a bowel movement. The patient denies syncope but states that he does not remember falling.
His Vital Signs
HR correlates with monitor, pulse not palpable at radial.
Initial BP 78/60
AAOx3, normal mental status, just wants to make a bowel movement.
Skin – Pale, more pronounced and white from the waste down. Skin was relatively dry.
First Possibility: Right-sided infarct with hemodynamic compromise leading to a syncopal episode. The syncope caused a secondary head injury which cerebrally herniated during transport. I would like to note that this is highly unlikely. Also, the patient did not improve with fluids, which would have happened with a traditional RV infarct.Second Possibility: It is much more likely that the patient had an atypical hemorrhagic stroke that presented with the first symptom of syncope. The changes on the 12-lead ECG could just be concurrent with cerebral ischemia. This is not completely understood, but theories involving nerve endings in the myocardium are abundant. The patient’s ICP would have increased during transport with the final result being cardiac arrest.Third Possibility: Abdominal aortic aneurism with severe secondary cerebral ischemia due to hemodynamic instability. I’m not fond of this idea even though the AAA fit the picture in the beginning, it does not explain the decorticate posturing.