This article appeared in the December 1987 issue of Jems Magazine.
Kate Dernocoeur has sometimes used the pseudonym Syd Canan
A 49-year-old female was flying from New York to Los Angeles for a job interview. During the flight, she began to feel anxious and ill. She contacted a flight attendant (who happened to be a registered nurse) and told her, ''I think I'm going to pass out." The RN walked her to an area in the plane where she could lie down. A registered respiratory therapist on the flight joined them and offered his assistance.
Shortly after lying down, the woman lost consciousness, became apneic, and her pupils dilated. She lost her radial pulses and only a "very weak, very fast carotid pulse'' could be felt. They initiated the first four breaths of CPR, and she woke up. Her radial pulse returned at a rate of 90/min., and her breathing returned to normal. This scenario repeated itself two more times and the pilot decided to make an emergency landing at the closest inajor city. He radioed ahead to have paramedics waiting for their arrival.
When the airport paramedic boarded the plane, he listened to the report from the RN and respiratory therapist while concurrently noting that the patient was awake, alert and had good skin color.
Vital signs: Pulse: 90 - B/P: 140/92 - Respirations: 16/min.
The patient had good mentation and refused to get off the plane to be treated. The pilot, hearing the patient's refusal to exit the plane and having made an unscheduled emergency landing for her, responded by ordering her off the plane. It was costing several thousand dollars a minute for the plane to sit on the ground. She countered by telling the pilot where he could put his plane. He gently escorted her off the aircraft, holding her arm in a hammer lock.
This left the paramedic with a patient who was not very cooperative. Nevertheless, he calmed her down long enough to complete the physical exam. This revealed bilaterally clear and equal breath sounds; a soft, flat, non-tender abdomen; and no significant changes in orthostatic vital signs from lying to standing. Her EKG is shown in Figure 1.
Just as the paramedic finished his exam, an airline employee brought him a phone and said, "This is her boyfriend. He says he has some important information that will help you take care of her.''
The male on the phone who identified himself as her boyfriend'' said, “Look, she has done this passing out stuff for the last couple of years. She has been through all kinds of tests and they can find nothing wrong. She is just an hysterical woman; give her a Valium and put her on an airplane. She has a very important job interview in the morning.”
The paramedic thanked the boyfriend for his valuable advice and hung up the phone. He then turned back to the patient and explained to her that a problem with her heart may be the cause of her passing out, and that if left untreated, it could give her additional problems or could even be fatal. Reluctantly, she agreed to be transported to the hospital – since the airlines would not allow her to fly without a physician's permission, anyway.
An IV line with D5W was established, 0, was started at 2 1/min., and the patient was transported without incident.
Case Discussion
This woman's case history is rather ominous. Syncope at rest, particularly when associated with respiratory arrest and a poorly perfusing tachycardia, paints a picture that appears cardiogenic. Apparently, the four quick breaths of mouth-to-mouth ventilation stimulated her recovery from each of these episodes. One possibility is that because the respiratory therapist was much larger than the patient, he may have hyperinflated her lungs with his breaths. This could have elicited a vagal response similar to a Valsalva's maneuver.
The patient's history warrants an evaluation of the EKG for causes of a tachyarrhythmia. Her EKG shows a normal sinus rhythm at a rate of 96/min. The axis is normal because there are upright QRS complexes in leads I, II, and III. The P-R interval, however, is 0.10 sec., which is shorter than the normal 0.12-0.20 sec. And if you closely examine the very beginning of the QRS, especially in lead III, you will note a slight slurring of the initial Rwave (Figure 2). When combined with a short P-R interval, this initial slurring of the QRS (called a delta wave) is indicative of Wolff-Parkinson-White syndrome (WPW).
WPW can cause pre-excitation of the ventricles in such a way as to generate a reciprocating tachycardia. In most cases, the delta wave is inscribed by the Kent bundles, which conduct impulses much faster than the AV node. Kent bundles are extensions of atrial muscle that extend into the ventricles. Their effect in some people is early activation of the ventricles. This causes the shortened P-R, the delta Wave, and usually also causes widening of the QRS complex.
The degree of QRS widening depends on how early the electrical impulse reaches the Kent bundle. If it is discharged at a time when the bulk of the ventricles have already been activated by the normal A-V conduction system, the P-QRS complex will appear as it does in this patient – only subtly abnormal. If it is discharged earlier than the normal conduction system, the majority of the ventricle is activated by that impulse, and a very shortened P-R with a widened RS results (see Figure 3).
In this case, the patient probably had a tachycardia due to WPW, which caused her syncope and apnea.
Pertinent Points
1. The gold standard of cardiac diagnosis is to listen to the description of events, to the patient's account of what happened and to how the patient is feeling. In this case, without even looking at an EKG or doing a patient exam of any type, tachyarrhythmia should be at or near the top of your list of potential causes for her episodes. Patient management with IV, 02, EKG monitoring, and transport to the hospital are indicated based on history alone.
2. When you evaluate the EKG, utilize clues from your history of the present illness to guide your investigation. In this case, the paramedic was looking for something that can cause tachycardias. He thus was able to find the very subtle delta wave which is the key to her further management.
3. Don't mess with a pilot who has had to make an unscheduled landing.
Suggested Bibliography
Becker, AE and Anderson, RH: "The WolffParkinson-White Syndrome and its Anatomical Substrates.'' The Anatomical Record 1981; 201:169-177.
Guiraudon, GM, et al.: "Surgical Repair of WolffParkinson-White Syndrome: A New Closed-Heart Technique.'' Ann Thorac Surg 1984; 37(1):67-71. Hamer, AWF, Vohra, JK, Sloman, JG and Hunt, D: "The Management of Patients with Suspected Wolff-Parkinson-White Syndrome – A Four Year Review.'' Aust. N.Z.J. Med. 1981; 11:629-638.
Kaku, T, et al.: "Wolff-Parkinson-White syndrome with bilateral accessory pathways both exhibiting antegrade and retrograde conduction." American Heart Journal 1981; 102(2):296-299.
Nelson, WP:" 'Wackcardia' in the Wolff-ParkinsonWhite Syndrome.' Medical Times 108(4):76-80.
Reddy, CP, Sartini, JC and Kuo, CS: "Paroxysmal Ventricular Tachycardia in Wolff-Parkinson-White Syndrome: Case Report and Review of the Literature.'' J Electrocardiology 1982; 15(4):403-410. Regos, L, Antaloczy, Z, and Nadas, I: "Correlation between Electrical and Mechanical Events of the Heart in the Wolff-Parkinson-White Syndrome." Adv. Cardiology 1981; 28:136-139.