Adam Unit One responds to a crane collapse incident downtown. The crew arrives on scene to find a victim lying on the ground next to a partially collapsed construction crane. Witnesses report the crane had been lifting a beam when the operator apparently lost control of it. The beam crashed into the crane, tipping it on its side. As the beam fell, it knocked over a pile of cement bags, which hit a construction worker. No other victims are reported. The crane operator is dazed but alert, oriented and ambulatory.

Prehospital evaluation & treatment

Photo By Eddie Sperling EMS crews apply a splint to the left leg of a construction worker. He was injured by falling cement bags after a crane operator experienced a syncopal episode.

One EMT evaluates the worker, while the second crew member assesses the crane operator. By this time, multiple units from multiple agencies have begun to arrive on scene.

The construction worker, a 37-year-old male, has no pertinent medical history, takes no medications and has no allergies. He complains of left leg and ankle pain. He remains fully alert and oriented and reveals that as the beam fell, he ran for cover. The pile of cement bags crashed down and hit his left leg, knocking him to the ground. He denies hitting his head or losing consciousness and reports no pain other than in his leg. His vital signs: blood pressure 130/78, heart rate 110 and unlabored respirations 20.

The physical examination reveals a deformed left ankle with good distal motor movements, sensory sensation and circulation. The crew notes no other obvious injuries. After splinting the patient's left lower extremity, the providers take full C-spine precautions and administer high-flow oxygen as per their standard trauma protocol. An ambulance transports him to the nearest trauma center.

The crane operator, a 45-year-old male, reports that while maneuvering the crane, he felt a little dizzy and lost control, but doesn't remember anything else until getting out of the displaced crane's cab. He also denies any pertinent medical history, has no allergies, takes no medications and doesn't complain of pain. He has stable vital signs. A team of EMS and fire personnel place him on oxygen, immobilize his C-spine and transport him to a nearby emergency department (ED).

Hospital evaluation

A trauma team evaluation reveals the injured construction worker has an isolated ankle injury and requires orthopedic surgery.

The crane operator has no traumatic injury, but an emergency physician works him up for a syncope evaluation. The hospital draws blood to test for drug and alcohol levels, as well as for routine electrolytes, hematocrit and hemoglobin levels. The initial evaluation includes an ECG and a head CT scan. All initial tests reveal no alcohol or illicit substances, no hypoglycemia, no anemia, no abnormal dysrhythmias and no bleeding in the head.

The patient is admitted for a syncope workup and equipped with a 24-hour continuous cardiac monitor (holter test) to continuously evaluate for dysrhythmias. The hospital also administers a tilt-table test in which a catecholamine, such as isoproterenol, is injected intravenously and vital signs are evaluated with the patient at different angles. The holter test proves negative, but the crane operator passes out during the tilt-table test. An electrophysiological study (EPS), which evaluates electrical conductance through the myocardium, is scheduled for the next morning.

The EPS reveals an extra pathway of current that causes a burst of ventricular tachycardia and accounts for the syncopal episode. This pathway is ablated (burned to eliminate the pathway's ability to conduct electrical current), and the patient stabilizes during the next several days. He begins medication and goes home after six days in the hospital with orders to follow up with his private physician, cardiologist and union physician.

Case review

Prehospital personnel frequently encounter patients who have experienced syncope, a sudden and transient loss of consciousness. Studies have found that syncope accounted for 3% of all ED visits and 1% of all hospital admissions. Any physiological event that decreases the required blood supply of 55 mL per 100 g of brain tissue per minute to adequately supply the brain with oxygen and glucose can lead to syncope. This can result from vascular problems, such as hemorrhage and hypovolemia; metabolic/endocrinologic disorders, including hypoglycemia and hypocalcemia; or central nervous system disorders, such as seizures.

In addition, cardiac abnormalities, as in the case of the crane operator, can be due to either electrical (dysrhythmia, arhythmia) or mechanical (MI, aortic stenosis) causes. Such medications as antihypertensives, particularly in the elderly, may also cause syncope. Benign causes can include vasovagal episodes at the sight of blood.

Regardless of the underlying reason, in syncope, the heart can't maintain a minimal cerebral perfusion pressure of approximately 20 mm of mercury, resulting in unconsciousness. Even though many patients regain consciousness and are alert on EMS arrival, prehospital personnel should not lapse into a false sense of security that their patient does not have a serious problem. They must not assume that all syncope patients collapse from a standing or sitting position or when they get up from a supine position. While syncope can occur in any position, an episode occurring with the patient supine almost always has a cardiac origin.

EMS crews are the front-line force in the detection of serious medical problems preceded by syncopal episodes. Don't neglect your history-taking, physical exam and patient monitoring skills when managing a syncope patient.

Hospital staff must identify the underlying pathology to determine whether a patient suffering from a syncopal event can be safely discharged home or requires admission for further evaluation and treatment.

Occasionally, a physician makes a hasty diagnosis of vasovagal syncope, also known as neurocardiogenic syncope, only to have the patient return with aggravated symptoms due to a more serious pathological process. Therefore, medical personnel should reserve this diagnosis until an extensive workup has been completed, particularly for very young or very old patients.

Discussion

This patient was not at the extremes of age, and-at the onset of this case-the scenario seemed like a straight-forward trauma situation. However, after a thorough evaluation, physicians found an underlying medical disorder. This interesting case reminds us of the importance of taking a thorough history when evaluating any patient. It's also a good example of how common problems can present uncommonly and how uncommon problems can present commonly.

Glenn Asaeda, MD, is deputy medical director with FDNY and an auxiliary police officer with NYPD assigned to the rescue unit out of the 61st Precinct in South Brooklyn.

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