Loss of Consciousness in a Patient With Viral Gastroenteritis

Case Study

A rapid response event was initiated by the bedside nurse for a patient with a brief loss of consciousness. The rapid response team quickly arrived to find the patient resting comfortably in bed. The patient was a 57-year-old female with a history of rheumatoid arthritis on methotrexate admitted for severe dehydration secondary to vomiting and diarrhea and was being treated with intravenous (IV) fluids. Prior to her hospitalization, she was taking care of her three grandchildren, who had similar symptoms of nausea and vomiting. The patient was attempting to ambulate to the bathroom with her nurse’s help. The patient had stood up from bed quickly and subsequently fell back into the bed. She was unresponsive for a few minutes and then regained consciousness without any intervention. After regaining consciousness, she was confused initially but recovered to her baseline within a few minutes. Per the nurse, there was no evidence of any urinary or bowel incontinence or any jerking motions after falling back onto the bed.

Vital Signs

Temperature: 98.1 °F, axillary
Blood Pressure: 102/58 mmHg
Heart Rate: 118 beats per min (bpm) – sinus tachycardia on telemetry
Respiratory Rate: 16 breaths per min
Pulse Oximetry: 100% on room air

Focused Physical Examination

A quick exam revealed a middle-aged female lying in bed in no acute distress. She was alert and orientated. Pupils were equal, round, and reactive, and there was no nystagmus noted. Her mucous membranes were dry and tacky. Her lungs were clear to auscultation. Her heart sounds demonstrated regular tachycardia without any appreciable murmur, and her radial pulses were strong and bounding. Her abdomen was soft, with mild diffuse tenderness and hyperactive bowel signs but without peritoneal signs. There was no calf tenderness or pedal edema on the examination of her extremities. She was able to recall the events before and shortly after falling back onto the bed. She reports she stood up, felt her vision dimming, and then woke up on her bed with her nurse standing over her. She denied any chest pain before this episode.

Interventions

A cardiac monitor was attached to the patient immediately. Then, 1 L of IV fluid bolus was initiated, given concern for volume depletion. Complete blood count (CBC), comprehensive metabolic panel (CMP), and serum lactate level were obtained, which were concerning for potassium level of 3 meq/L. Stat electrocardiogram (EKG) was obtained, which showed sinus tachycardia. No acute ST changes were seen. Computed tomography (CT) of the head was deferred given the lack of focal neurological signs on exam. The patient was retained on the floor for further rehydration.

Final Diagnosis

Syncope secondary to orthostatic hypotension in the setting of volume depletion.

Syncope

Syncope is a brief and abrupt loss of consciousness with a return to the patient’s mental baseline after the episode.

Syncope can be broken down into four main categories based on the underlying pathologic condition. Having a general understanding of each main type can help direct the proper next steps in evaluation, especially during a rapid response. The four main syncope categories are cardiac, orthostatic, neurally mediated (reflex), and neurologic/other ( Table 43.1 ). The most common type of syncope is vasovagal syncope, which is a subset of the reflex category. Vasovagal syncope is induced by anxiety, painful stimuli, or fear.

Table 43.1

Classification of syncope

Classification	Examples	History/associated features
Cardiac	Arrhythmias, obstructive cardiomyopathy, structural heart/valvular disease, acute cardiovascular pathologies (pulmonary embolism, aortic dissection, myocardial infarction)	Risk factors for cardiac disease, family history of sudden death, heart murmur on exam, hypercoagulable states
Orthostatic	Volume depletion, autonomic dysfunction, drug induced ( Table 43.3 )	Poor intake, vomiting, diarrhea, spinal cord injury, Parkinson disease, alcohol use. Drugs: anti-diabetic, antihypertensives, vasodilators
Neurally mediated (reflex)	Situational, vasovagal, carotid sinus syndrome	Phobias, stressful situations, head rotation/shaving/tight collars cause symptoms, preceding nausea
Neurologic/other	Vascular steal syndromes, cerebrovascular accident risk factors, basilar artery disease, psychogenic	Somatization disorders, abnormal neuro exam, use of arms causing syncope

Various other conditions can mimic the clinical presentation of syncope, and special attention should be paid to these conditions to make sure they are not missed. These are listed in Table 43.2 .

Table 43.2

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