[Indaemed_Freelist.Org] Re: [indaemed] Re: Syncope evaluation [was Re: Re: NMS]
- From: USM Bish <bish@xxxxxxxxxxx>
- To: indaemed@xxxxxxxxxxxxx
- Date: Sat, 20 Mar 2004 00:50:13 +0530
On Fri, Mar 19, 2004 at 09:09:33PM +0530, Sanjiv Sharma wrote:
>
> indeed there were tell tale signs of syncope: to quote briefly
> about the first episode of VVS last year, the History of
> present illness was something like this-
Now the jigsaw puzzle seems to fit into place ... this was the
info that was needed, which probably would have avoided all the
beating around the bush ...
> He reportedly lost consciousness during pre-flight briefing at
> 0540 hours.
This is important ... hormonal dips, arousal state etc
> This happened when he stood up to answer an emergency recall
> procedure. After narrating the emergency procedure, he
> continued to stand still for a couple of minutes.
Why ? was he asked to stand ? Psy overlay ? Absence seizure ?
> when he felt dizzy, had blurring of vision and cold sweating
> before fainting.
These are final symptoms, when cerebral oxygenation is
affected, may not give much clue to the cause ... yes, VVS
could also produce these.
> He fell flat on the face, sustaining a laceration wound on his
> chin.
Confirmation that he was not freigning. Except for Charlie Chaplin
there are no recorded instances of voluntary "dead-man's-fall" !
> DMO, who was present for the pre-flight medical briefing, did
> not observe any jerking movements of limbs, incontinence,
> tongue bite or any other suggestive signs of seizures.
Rules out convulsive pathology (GTCS) ...
> He found that the patient was sweating, looked pale and had a
> pulse rate of 54 beats per min.
This is expected in most cases of LOC in recovery phase. The
low HR may be a reflection of his otherwise low HR pattern.
> He regained consciousness spontaneously in a few minutes and
> could recollect the events preceding the faint. However, while
> being carried on a stretcher he felt "too tired" to open his
> eyes or to respond to verbal command.
Hang on here ! This is IMPORTANT. Are we dealing with a case of
TA (Typical Absences) ? Eye lid Myoclonia with Absences (MEA)
and perioral myoclonia is known in the absence epilepsy group.
This is the presentation of TA in almost 40% of cases ! There
are high chances that he may have hippocampal affection! What
does the EEG/ stress EEG show ? Any findings in the CT/ MRI ?
> The ambient temperatures those days were about 22 -25? C.
Just about rules out hypothermia ... not very significant.
> The patient was feeling unduly fatigued on the day of this
> episode.
Significant again, pointing more towards a TA rather than VVS.
Recovery after VVS would be back to SHAPE-I, whereas post-ictal
weakness/ fatigue for some time is known in epilepsies.
> woken up at around 0400 hours.
Normal, if he was to get to work at 5 ;-)
> He was anxious since he was scheduled to fly his first solo
> sortie that day. He had been sleeping for about four to five
> hours each night for the past 3 to 4 days instead of his usual
> seven to eight hours, busy preparing for Aviation Medicine
> Final test.
Significant again. Psychological stressors normally precede most
TA episodes. High GABA depletion.
> He used to consume about seven to eight cups of coffee daily;
> except that that morning he did not have any drinks or food. He
> had his dinner at about 2030 hours the previous night.
Personally I feel, neither presence nor absence of caffein nor
any hypoglycaemic spell is operative here ... I believe, he was
a heavy duty aerobic fitness freak ... blood sugar vagrancies
would have manifested in such work-outs much earlier.
>
> just for the records ... now we need to put Col Tripathi's and
> Anuj's findings this time around and then see: whether or not
> it was Syncope?
It is definitely a syncope, does not appear to be pure
psychological in origin, (not a hysterical "fit" at least).
> If it was syncope, was it VVS?
My guess is NO. I would put my first bet on TA (variety of
absence seizures), non-motor type. This is from the history
given above. DD would go to all others associated with TA viz:
Temporal lobe, Panic Disorder, Occipetal lobe, Frontal lobe,
Psychogenic non-convulsive siezures ... what else ?
The symptoms stated above cannot be fitted with LOC of vascular
or cardiac origin. VVS ? Highly unlikely.
> If it was VVS all three times or one episode of VVS and two of
> Hypoxia induced LOC ?
It was probably the same pathology triggered by different
stimuli on the three occasions. The first LOC at briefing was
by all possibilities due to psychological stressors mentioned
above. The hilar somatostatin-immunoreactive neurons, are
affected readily by GABA influences, as well as hypoxia through
the same GABA depletion mechanism. Intense psychological
pressures lower GABA levels. Similar lowering is expected at
30,000 ft of hypoxia. The acute hypoxia, has done the final bit
of GABA depletion, thus accounting for his reduced TUC, which
was perhaps not demostratable at lower altitudes with higher
PaO2 levels, and compensatory mechanisms operative, and GABA
reserves still at play. This theory is based on facts stated in
inputs give today ... I admit, the hypothesis is purely from
recall ... I'll come back on this after some reading ! But I
think, I am on the right track ...
> and finally to decide what is good for his safety and what is
> good for his career?
Now, with the revised history, with facts pointing to perhaps
organic pathology of the brain, manifesting with what seems to
me the MEA variant of an absence seizure, the disposal is self
explanatory ...
Whether investigated with the required neurological/ psycho-
logical battery of tests, I do not know.
I would also like to know details of the hypobaric runs, just
to fit some missing links of the puzzle. If it is a case of TA,
like I suspect, exposing him further to hypoxia would hardly
help the cause of the individual or Service ...
I seem to have shot off quite a few things "off the cuff" or
"off the (bald) head" ... it is time to get down to the books
and do some serious reading ;-) I am out of academics for quite
a while now ... the metal is intact, but the rust shows ;-)
Any counter theories ?
Just my 2p
Bish
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