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12-Lead ECG and Patients with Syncopal Episodes

Posted by Jessica Carmichael on 8/6/12 10:13 AM

This is the first in a series of articles from Public Safety Group author Christopher Touzeau that will explore the cardiac causes of syncope and illustrate the importance of acquiring an ECG on all patients who experience presyncope or syncope.

Emergency Medical Services (EMS) personnel frequently respond to patients experiencing syncopal episodes. Syncope accounts for 3% of emergency department visits and 6% of hospital admissions yearly. Syncope is defined as a brief loss of consciousness caused by transiently inadequate blood flow to the brain.  EMS personnel often minimize the syncopal event and dismiss it simply as a sign of anxiety or a vasovagal reaction. Although increased vagal tone is often responsible for inadequate cerebral perfusion and subsequent loss of consciousness, it is critical to exclude the postural, neurological, and cardiac causes first.

Case Study

You are dispatched to a 32-year-old male who experienced a syncopal episode while grocery shopping. Upon arrival, you find an awake, alert, and oriented adult male. He apologizes profusely for disturbing you and tells you he is fine. He denies having chest pain, shortness of breath, or unexplained sweating. He states that he skipped breakfast earlier in the day and had quite a bit of alcohol the night before. You explain the importance of checking his vital signs and blood sugar and he agrees to let you check them. His vital signs are: blood pressure 124/74, pulse 62, respirations 18, SpO2 99%, blood sugar 90 mg/dL. His lung sounds are clear, skin cool, dry and pink, abdomen soft and non-tender. Your partner explains the importance of acquiring an ECG and the patient agrees.

12-Lead ECG

  • What is your interpretation?
  • Do you see anything life-threatening?
  • What is your next course of action?
  • Does this patient need to be transported to the hospital?

Case Study Summary

The ECG reveals a sinus rhythm. There are no signs of chamber enlargement, axis deviation, or myocardial ischemia. Close inspection of leads V1-V2 reveals an incomplete right bundle branch block (rSR’ pattern), ST segment elevation, and T wave inversion, consistent with Brugada Syndrome.

Brugada Syndrome is a genetic condition involving a sodium channel abnormality in the heart’s cells. The disease causes ventricular tachydysrhythmias that may lead to syncope or sudden death. The disease primarily affects males and is most commonly discovered in the third or fourth decade of life. Brugada Syndrome is reported to cause 5% of all sudden cardiac arrest cases.

This patient should be transported to the emergency department for further evaluation. Treatment for Brugada Syndrome includes electrophysiologic testing and placement of an automated implantable cardioverter-defibrillator.

Clinical Pearls

  • Never dismiss syncope in the prehospital setting.
  • Acquire a 12-Lead ECG on all patients presenting with presyncope or syncope and scrutinize the tracing for changes consistent with life-threatening diseases.
  • Brugada Syndrome is characterized by:
    • An incomplete right bundle branch block (rSR’ pattern in leads V 1-V 2).
    • ST segment elevation in leads V 1-V 2.
    • T wave inversion in leads V 1-V 2.

Suggested Readings

Christopher Touzeau, MS, NREMT-P, RN, caught the EMS bug in 1992 and has been a professional firefighter paramedic in Montgomery County, Maryland since 1995. He developed a passion for teaching early in his career and has developed and taught EMS courses in numerous areas around the country and world.

Mr. Touzeau is the author of ECG Cases for EMS. Learn more about this resource



Topics: 12-lead ECG, 12-Lead, ECG, EMS

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