Hot Seat #176: Denouement

Posted on: September 24, 2021, by :

The Case: A 15-year-old with remote history of epidural hematoma and craniotomy presents after a brief loss of consciousness.

Here’s how you answered:

Our case this week involves a common presentation with a few twists. A 15-year-old boy presents after a brief loss of consciousness without signs of seizure or persistent altered mental status. His history of a remote epidural hematoma and craniotomy complicates his case, as does some relative bradycardia for age upon presentation.

The wide majority of respondents chose to pursue some workup, although there was a wide range of approaches. EKG was the most common choice, followed by POC glucose, and orthostatic VS. A discussion ensued related to the clinical utility of orthostatic vital signs. Most providers agreed that they contribute little to this case, or in emergency department workups more broadly, and are often positive even in healthy patients.

Regarding head imaging, only 8% of junior respondents chose to pursue a head CT, but 29% of senior respondents chose the same. Whereas head CT is not routinely pursued in cases of suspected vasovagal syncope, this patient’s history of craniotomy, as well as his relatively older age and lower risk of adverse effects from radiation, likely contributed to the senior respondents’ increased likelihood to pursue imaging.

The workup pursued included basic labs and EKG without head imaging. It was notable just for EKG with mid-50s HR and first-degree AV block. Cardiology was consulted and deemed it unlikely to be relevant to his brief loss of consciousness, especially with interval resolution of symptoms and an otherwise-normal EKG. He was ultimately discharged home with outpatient cardiology follow-up and a diagnosis of vasovagal syncope.

The information in these cases has been changed to protect patient identity and confidentiality. The images are only provided for educational purposes and members agree not to download them, share them, or otherwise use them for any other purpose.

Walter Palmer

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