A 43-year-old man with syncopal episode and bradycardia 2 weeks after a motor vehicle crash.

Abstract

When the paramedics arrived, they found the patient awake and alert, but with amnesia regarding the incident. There was no evidence of seizure activity. The patient’s vital signs before arrival at the emergency department were as follows: blood pressure, 1 lo/60 mm Hg; heart rate, 66 beats/min; and respiratory rate, 16 breaths/min. Cardiac monitor showed normal sinus rhythm without ventricular ectopy. An IV line of normal saline solution was established and the patient was given supplemental oxygen at 3 L/min by nasal cannuld. On his arrival at the emergency department, the patient’s initial rhythm was sinus bradycardia, with a rate of 56 beats/min. His blood pressure was 90/50 mm Hg, his respiration was unlabored at 16 breaths/ min, his tympanic temperature was 35.5” C (96.1’ F), and his skin was pink and dry. The patient’s pupils were equal and reactive to light. Breath sounds were clear; heart sounds were normal without murmur. His abdomen was soft, nontender, and nondistended, with active bowel sounds. The patient denied any significant previous medical problems and was not receiving any medications. He also denied any prodromai symptoms, including nausea, dizziness, dyspnea, and chest pain. His only complaint was a headache, which he reported having had intermittently for 2 weeks after a motor vehicle accident. Further inquiry revealed that the patient had been the restrained driver of a car that was hit broadside on the driver’s side. He stated that he had hit his chest and head, but had no loss of consciousness and no abdominal complaints. According to the patient’s rep::rt, he was initially evaluated at a clinic and released with a diaqnosis of “minor injuries.” No laboratorytests or x-ray studies were done at that time. The patien! stated that he had also sustained a “whiplash” injury 4 weeks before, when he fell from a forklift. He did qot seek medical care at that time. Thirty minutes after his initial evrxiuation, sinus bradycardia with a rate of 46 beats/‘min developed. The patient remained free of symptf:)ms and was observed while a 12-lead EKG was tats/min lying to 70 beats/min standing. Blood pressure lyinq was 1 lo/60 mm Hg; standing, it was 120!?~4 mm Hg. De spite these findings, the ED physician c:ho:;e to admin ister a fluid challenge of 500 ml norma i saline solution, without change in the patient’s condition. The patient’s history of recent trauma and intermittent headaches warranted a coiliputed tomographic scan of the head. The patient was accompanied by a nurse and remained on a I--,irdiac monitor during the prccedure, which was une;,eI.:tful. The results were normal. After returning to the emergency t.lepartment, the patient awaited laboratory result:-, and was ob-