SYNCOpedia

Hypotension due to straining in a patient with a high spinal cord lesion: Difference between revisions

Page Discussion

Hypotension due to straining in a patient with a high spinal cord lesion (view source)

Revision as of 13:35, 9 July 2014

138 bytes added ,  9 July 2014
no edit summary
No edit summary
No edit summary
Line 3: Line 3:


{{case_present|
{{case_present|
A 17-year-old boy was referred because of longstanding complaints of fainting. He experienced his first episode at the age of 4 during a venipuncture [1]. Since then he often fainted, first with venipuncture, but later also when he merely thought of blood, needles or other medical procedures. He has no complaints during prolonged standing. His mother experienced the same problem when she was young.  
A 17-year-old boy was referred because of longstanding complaints of fainting. He experienced his first episode at the age of 4 during a venipuncture <cite>VanDijk</cite>. Since then he often fainted, first with venipuncture, but later also when he merely thought of blood, needles or other medical procedures. He has no complaints during prolonged standing. His mother experienced the same problem when she was young.  


When he was 16 he was evaluated by a pediatrician. When discussing venipuncture, syncope occurred. The patient showed some myoclonic movements and was unconscious for less than five minutes. After regaining consciousness he was pale, sweating and nauseous. Physical examination, ECG and echocardiography showed no abnormalities. On 24 hour Holter monitor recording sinus rhythm, with frequent bouts of sinus arrhythmia ranging from 110 to 58 bpm was observed.
When he was 16 he was evaluated by a pediatrician. When discussing venipuncture, syncope occurred. The patient showed some myoclonic movements and was unconscious for less than five minutes. After regaining consciousness he was pale, sweating and nauseous. Physical examination, ECG and echocardiography showed no abnormalities. On 24 hour Holter monitor recording sinus rhythm, with frequent bouts of sinus arrhythmia ranging from 110 to 58 bpm was observed.
Line 15: Line 15:
{{clr}}
{{clr}}


His blood-injury phobia was treated using systematic desensitization with muscle tensing and cognitive techniques [2,3] under surveillance of the pediatric resuscitation team. Cognitive behavioral therapy was used to teach him to apply realistic and reassuring thoughts to the physical symptoms he saw as alarming.  
His blood-injury phobia was treated using systematic desensitization with muscle tensing and cognitive techniques <cite>Hellstrom</cite><cite>Krediet</cite> under surveillance of the pediatric resuscitation team. Cognitive behavioral therapy was used to teach him to apply realistic and reassuring thoughts to the physical symptoms he saw as alarming.  


The experience during behavior therapy that straining his muscles immediately diminished negative bodily sensations resulted in effective control over the fear-provoking venipuncture situation. After 10 training-sessions, he was able to undergo venipuncture without fainting. The patient has had no fainting episodes for a follow-up period of 18 months.
The experience during behavior therapy that straining his muscles immediately diminished negative bodily sensations resulted in effective control over the fear-provoking venipuncture situation. After 10 training-sessions, he was able to undergo venipuncture without fainting. The patient has had no fainting episodes for a follow-up period of 18 months.
Line 26: Line 26:
Vasovagal syncope is a frightening but usually benign condition. A vasovagal collapse can occur after certain triggers (emotional or prolonged standing) which cause a reduction in sympathetic outflow to the systemic circulation and augmentation of efferent vagal activity. In the present case only thinking about blood taking induced an emotional faint. Usually vasodilatation is the most important cause of hypotension in syncope, while bradycardia is often moderate and of late onset.  
Vasovagal syncope is a frightening but usually benign condition. A vasovagal collapse can occur after certain triggers (emotional or prolonged standing) which cause a reduction in sympathetic outflow to the systemic circulation and augmentation of efferent vagal activity. In the present case only thinking about blood taking induced an emotional faint. Usually vasodilatation is the most important cause of hypotension in syncope, while bradycardia is often moderate and of late onset.  


Treatment with a pacemaker, therefore, has no effect on hypotension in the vast majority of such patients or on the speed with which hypotension occurs [4-6]. The asystole clearly was instrumental in causing syncope in this patient. The pronounced sinus arrhythmia during Holter monitoring and forced breathing indicate this patient’s susceptibility to vagal stimulation. Vasovagal syncope with prolonged asystole is uncommon. Deal et al found a cardioinhibitory response (asystole ≥ 5 seconds) in 4.5% of syncopal children during tilt-table testing [7].   
Treatment with a pacemaker, therefore, has no effect on hypotension in the vast majority of such patients or on the speed with which hypotension occurs <cite>Sra</cite><cite>Hainsworth</cite><cite>Connolly</cite>. The asystole clearly was instrumental in causing syncope in this patient. The pronounced sinus arrhythmia during Holter monitoring and forced breathing indicate this patient’s susceptibility to vagal stimulation. Vasovagal syncope with prolonged asystole is uncommon. Deal et al found a cardioinhibitory response (asystole ≥ 5 seconds) in 4.5% of syncopal children during tilt-table testing <cite>Deal</cite>.   


Intense fear of seeing blood is seen in 2-4.5% of children and adults. Blood-injury phobia usually starts in childhood, is often familial and is a distinctive focal phobia. Exposure therapy has been described as a valuable method to treat it [8]. In serious cases like this, great care must be taken to motivate patients for treatment, because of their tendency to withdraw from any confrontation with fear-provoking stimuli.
Intense fear of seeing blood is seen in 2-4.5% of children and adults. Blood-injury phobia usually starts in childhood, is often familial and is a distinctive focal phobia. Exposure therapy has been described as a valuable method to treat it <cite>Marks</cite>. In serious cases like this, great care must be taken to motivate patients for treatment, because of their tendency to withdraw from any confrontation with fear-provoking stimuli.


We conclude that vasovagal syncope due to bloodphobia, even with very long periods of asystole, can be treated using psychological techniques instead of pacemaker implantation  
We conclude that vasovagal syncope due to bloodphobia, even with very long periods of asystole, can be treated using psychological techniques instead of pacemaker implantation  
April
214

edits

Retrieved from "https://en.syncopedia.org/wiki/Special:MobileDiff/246"