[Indaemed_Freelist.Org] Re: [indaemed] Re: Syncope evaluation [wasRe: Re: NMS]
- From: Lt Col KK Tripathi <tripfamily@xxxxxxxx>
- To: indaemed@xxxxxxxxxxxxx
- Date: Sat, 20 Mar 2004 10:06:04 +0530
Dear Wg Cdr Bish,
As far as I remember, EEG even after provocation, was non contributory.
No abnormality was detected in CT/MRI.
A low pulse rate falling to 37 per minute (and remaining so for a good 15-20
sec) is more in favour of VVS.
With regards,
Lt Col KK Tripathi
----- Original Message -----
From: "USM Bish" <bish@xxxxxxxxxxx>
To: <indaemed@xxxxxxxxxxxxx>
Sent: Saturday, March 20, 2004 12:50 AM
Subject: [Indaemed_Freelist.Org] Re: [indaemed] Re: Syncope evaluation [was
Re: Re: NMS]
> 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
>
> --
> :
> --------------------------------------------------------------
> Wg Cdr (Retd) US Mohalanobish bish@xxxxxxxxxxx
> GF-01, Carleston Classic usmbish@xxxxxxxxxxxxxx
> 03, Carleston Road +91-80-30611448
> Cooke Town, Bangalore - 560005 98451-71863 (Mobile)
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>
>
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