Hypotension due to straining in a patient with a high spinal cord lesion

N. van Dijk*, S.C.J.M. Velzeboer*, A. Destrée-Vonk§, M. Linzer+ and W. Wieling*
Departments of * Medicine and § Pediatrics, Academic Medical Centre, University of Amsterdam, Amsterdam (The Netherlands), + University of Wisconsin, Madison, Wisconsin (USA)

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. 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. During cardiovascular reflex investigation, the patient had a blood pressure of 106/54 mmHg. During deep forced breathing, marked sinus arrhythmia was observed. Standing up elicited a normal blood pressure and heart rate response. The investigators discussed with the patient’s mother the normal results of the tests and mentioned that a “blood taking” provocation might be necessary at another occasion. About 1 minute later the patient felt nauseous and started sweating. Bradycardia developed. The patient then became asystolic for almost 50 seconds. He was put on the bed and cardiac massage was applied. When reviewing the ECG afterwards, the first escape beat was almost at the same moment of CPR initiation. After 2 minutes the patient regained consciousness with a normal blood pressure and bradycardia of 45 bpm (Figs. 1 and 2). Syncope due to an emotionally-evoked vasovagal response with extreme bradycardia was diagnosed. Considering the clear cause of fainting and with the patient’s age in mind, we decided not to implant a pacemaker but to refer the patient to the Pediatric Psychosocial Department.

Editor's comments

Table 2:Typical Premonitory Symptoms for Reflex Syncope
Lightheadedness, dizziness Palpitations Weakness Dimming or blurred vision Fading hearing, tinnitus Nausea, epigastric distress Feeling warm or cold Facial pallor Sweating, dilated pupils

References

Wieling pmid=15310717