Fainter.... advice

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Greetings.

Interesting case. 21 yr old female with bilateral Onycryptosis. Otherwise completely healthy, no meds or allergies. Except that she faints and convulses with certain stimulus. Most specifically needles. Once a microlet (pin prick for blood sugar). Once witnessing acupuncture on a third party. Each event was accompanied by convulsions and a pseudo delirium on recovery. She has never needed dental analgesia.

This young lady presented to another pod for nail avulsion who when introducing xylocaine by needle experienced the above results. He abandoned the procedure at that point. She is now looking for the nail avulsion procedure to be carried out. She feels that emla (topical lidocaine /prilocaine) may reduce what appears to be a vaso vagal response.

My question is; does anyone have any advice, caveats on a case like this? Would you do it? How would you do it. Would you expect the "spell" to be a one off at the time of freezing or repeating during the procedure?..

Brendan.

 

Just do it.

Its far easier to do the job when the patient is unconscious.

But seriously. Lay the patient down. This should be mandatory for any invasive technique. Have an assistant nearby. Once (if) she faints and passes out, just stop for a second of two while she does a little dance (convulsion), then continue once you are satisfied anaesthesia is achieved. The assistant can keep an eye on the other end.

Its gotta get done, the only other alternative is to have her in a hospital operating theatre, and even then it will probably be the same outcome.

Usually see a person like this every year or two.

LL

 

Hi Brendan,

I totally agree with LL. I would also add though ensure the room is well ventilated & if she does faint elevate her feet until she comes to & reassure her. I would also tell her to eat as normal prior to procedure (keep something handy to catch anything that doesn't stay down). Loose clothing (the patient not you) may also help her to remain comfortable. I have experienced a few fainters too & the thing I have found common in each episode is the distress the person feels when they come round.

Kind regards,

Mandy.

 

Entonox (or similar) is really helpful for this problem and usually allows LA to be carried out without difficulty. As always, contact should be made with the GP and a very careful Hx noted. Per LL and Twirly, a colleague/assistant present is mandatory for both the patient, and your protection.

All the best

Bill

 

Hi
Make sure they have a wee before starting the procedure. Had a patient recently who had a very similar episode and had an unfortunate accident all over my couch ! Far more embarrassing for the patient than for me.
Deborah

 

Have her wear a motorcycle helmet? Kidding.

Can you prescribe an anxiolytic to take before coming in?

Place her in Trendelenburg to begin with prior to the procedure and make sure you have an assistant to spot her so she doesn't get injured. Make sure the room is a comfortable temperature and well-ventilated.

 

Apart from the other advice - keep the vision of all thing surgical away from the patient. ie use a sterile curtain type of approach.

I would also recommend another consult in between the 1st and the PNA- get to know the patient answer any questions so the patient knows you a little more, feels confident etc.

Also book this patient in last so you are not stressed re time and the patient will relax knowing there is no-one outside waiting etc, just you the friend and her.

Lucky they told you I had a patient who would faint - I did asked about any other medial conditions I should know about bloke said nothing - did the PNA he fainted just as I took off the torque - got him settled, dressed the toe up rang the wife who´s 1st question was did he faint? :bang:

When she picked him up even the 4 -5 year old twin girls were making fun of the Dad - when I asked why he did not tell me - Wife answered it a guy thing you should know that - :craig:

 

Mike,
Dont be too hard on the guy, its difficult sitting at the other end of the chair and relaying your relevant life story. I recently underwent three years worth of various treatments for migraine with pretty poor results until my wife thought to mention to the clinician as we were leaving the building that I had previously fractured my skull - twice! Apparently this is quite a relevant piece of medical history when treating migraine but it just didn't occur to me:bash:

 

Few things. First off, is this a syncope type faint or McKeith syndrome? I've seen both in clinic... If its the latter, don't play.

Secondly, keep in mind that the state of your mind will very largely dictate the state of hers. Sometimes when patients tell you this sort of thing they are inviting you to enter into this little drama with them. Much like the child who is tearful and upset when they are hurt if with someone who is likewise upset, but brightens up or does not even go into the "fuss" stage if the adult does not indulge it. Whilst care must be taken, don't get sucked into their mindset.

This is where experienced surgeons / Pods tend to score. Because they've seen it dozens of times they are quite unbothered with it. If you've never seen someone convulse before it tends to make you drop out of your own bottom. That fear refracts into your patients and can become a self fulfilling prophecy. On a subconcious level, if they sense your fear, they will share it. If they sense your confidence they'll share that too.

 

Thank you all for your insightful responses.

Upon further questioning, it turns out that several members of the patients family (mother, brother and sister) also have the same syncopal episodes. The following may be of some interest.


Vasovagal syncope is an exaggerated form of the common faint affecting all age groups. Aetiology is unknown but the tendency for the disease to run in families has previously been noted. Aim: To determine the true prevalence of family history in subjects with a definitive diagnosis of vasovagal syncope made by positive head up tilt with symptom reproduction. To determine the strength of the genetic effect in vasovagal syncope by calculation of sibling (λs) and offspring (λo) relative risk. Haemodynamic responses to head up tilt were also examined in a sample of first-degree relatives of those with vasovagal syncope. Results: All subjects identified from the Cardiovascular Investigation Unit database with a definitive diagnosis of vasovagal syncope (n = 603) between 1993–2001 were asked to complete a questionnaire. 19 % had positive family history for blackouts or faints. From these pedigrees and using a crude estimate of population prevalence, sibling and offspring relative risk was calculated: λs = 1080, λo = 1356. Eleven first-degree relatives from 6 families attended for head up tilt testing with glyceryl trinitrate (GTN) provocation (4 unaffected, 7 affected). All subjects had symptoms in response to tilt in association with a range of haemodynamic responses. Conclusions: Vasovagal syncope has a strong genetic component. Elucidating underlying genetic mechanisms may lead to more effective, specific treatments.
From:
Prevalence of family history in vasovagal syncope and haemodynamic response to head up tilt in first degree relatives
Preliminary data for the Newcastle cohort

Julia L. Newton, Roseanne Kenny, Joanna Lawson, Richard Frearson and Peter Donaldson

 

I had a similar experience with a young Lad of 19 some years ago. He also had a mild onychocryptosis (no avulsion required), but somehow we got on the subject of needles, and when i looked up he had fainted and was fitting.
He recovered fairly quickly and of course i stopped the treatment. I wouldn´t allow him to drive as he was still a bit disorientated, and I arranged for his father to collect him. I discovered later that day that he had a needle phobia which caused this reaction even when he just thought / talked about needles. His parents were concerned that his "mates" would use this against him as a bit of a joke and were considering a course of hypnotherapy. I wish i´d had this information beforehand, but then why would they have considered that as I was not going to inject.
he had undergone a lot of medical procedures as a younster and this fear had remained with him.

Regards,
Leigh

 

Hi

to Simplify

A faint is natures way of making you lie down to get more oxygen to the brain, simple as that.

If you sit a patient up that has fainted they Will convulse.

In my former life I have Tx hundreds of patients where well meaning bye standers would be insistent the pt must sit up and were confronted with a sometimes violent convulsion.

I agree with the earlier posts, have someone with you chat with the patient from the time they come in till the tx is complete, position them properly.

If they start to feel faint tell them to squeeze the cheeks of their bum together as hard as they can !! ( The Glueteals are powerful large blood filled muscles that will force more blood / oxygen into the circulation and to the brain) by which time the procedure should be all but over.

Let them sit up in their own time and give them plenty of fresh air before they try to walk out.

Hope that helps

Cheers
D

 

Brendan:

In a situation such as this, you or her family physician may prescribe 5 mg of Valium to be taken orally 30 minutes before the expected procedure. This greatly reduces the anxiety of injections and will probably also reduce her fainting episode. I prescribe Valium for patients about 4 times a year who have had similar anxiety related issues with injections and it works like a charm. With Valium on board, these people have a much easier time with the whole process, are relaxed and generally happy to have their nerves calmed for the procedure.

Of course, things like having the patient completely flat on her back during the procedure, not allowing her to see the needle or syringe, having someone in the room with you to assist and also keeping the room cool will also help things along with this type of patient.