What is catatonic shock? Are there any ways to improve it?

Shock is also called syncope; let me first talk about my point of view. If there is something wrong, please let me know:

1. Diagnostic idea: First, start from the patient’s main complaint of recurrent palpitations. For 7 years, he suffered from worsening dizziness and fatigue and syncope twice a day. At this time, we had the impression that the patient was caused by insufficient blood supply of cardiac or cerebrovascular origin. We then carefully analyzed whether the patient's syncope occurred after urinating or defecating. Based on the patient's medical history, he had palpitations 7 years ago. It worsened after obvious activity, but there was no obvious chest tightness or pain. I went to the hospital to consider the possibility of coronary heart disease. He was hospitalized in our department 20 days ago due to significantly elevated blood pressure. At that time, the electrocardiogram showed frequent ventricular premature ejaculation. At this time, cardiogenic causes were more likely to be considered, but TIA could not be completely ruled out.

2. Complete examinations should be carried out: patients should complete electrocardiogram, preferably Hottle, echocardiography, electrolytes to exclude electrolytes caused by low potassium and magnesium, head CT to exclude cerebrovascular accidents and other corresponding examinations .

3. Possible diagnoses: 1: CHD

2: Arrhythmia: Frequent premature ventricular disease?

Three: Hypertension

Fifth: Cardiac insufficiency?

Four: TIA?

Newbies on the road! Tell me your opinions and shortcomings. Please give me your advice!

1. Diagnostic ideas:

1) Clarify the cause of syncope: Possible causes of syncope include hypovolemia, arrhythmia, TIA, cerebral ischemia, vasovagal disease, etc., among others Carotid artery stenosis and the like.

According to the patient's medical history, first of all, the patient's stool was dark in color. Although the patient had a recent history of eating pig blood, Shangxiao could not be completely ruled out, so hypovolemic syncope caused by Shangxia bleeding could not be ruled out. The electrocardiogram of the second patient more than 20 days ago showed frequent ventricular premature episodes. The patient still has palpitations and discomfort. Therefore, syncope caused by arrhythmia (Ashe syndrome?) cannot be ruled out. The third patient has TIA and cerebral ischemia. There are no obvious abnormalities in head CT, which basically excludes cerebral ischemia. TIA may be related to arterial stenosis. Carotid artery color ultrasound and transcranial Doppler are recommended. Vasovagal syncope occurs more often in young women and is temporarily excluded.

2) Examinations should be completed: 1. Routine blood, urine, and feces routine: if there are no abnormalities, basically rule out upper bleeding;

2. 24-hour dynamic electrocardiogram: the diagnosis of arrhythmia is Required;

3. Carotid artery color ultrasound and transcranial Doppler to rule out arterial stenosis;

Possible diagnosis: 1. Based on the patient’s medical history, I think it is the most likely It's arrhythmia - frequent premature ventricular episodes.

Secondly: carotid artery stenosis, insufficient blood supply to the vertebrobasilar artery

Thirdly: upward elimination In addition, generally patients with hypertension and palpitations should have their cardiac enzyme spectrum checked regularly when they are hospitalized. , after all, his blood pressure has reached 190/100mmHg, and has not been controlled by systematic medication, so it is better to rule out myocardial infarction!

Causes of syncope:

1. Cardiogenic (arrhythmia): There are risk factors such as old age, male gender, high blood pressure, symptoms such as palpitations, and "premature beats" were also found during physical examination. .

2. Vasovagal syncope: I have had high blood pressure and heart palpitations for 7 years. I have not had syncope in the past. The two syncopes that have occurred recently were both at night, during urination and defecation. There may be blood pressure control. Poor or orthostatic hypotension, etc., or vagus nerve excitement, etc. Further examinations: 1. 24-hour dynamic electrocardiogram; 2. Cardiac color ultrasound; 3. Coronary angiography if necessary.

1. Patient, male, 63 years old;

2. Heart palpitations for 7 years, worsening with dizziness and fatigue and syncope twice a day (main complaint is irregular)

The patient had palpitations without obvious triggers 7 years ago, which worsened after significant activity and the symptoms recurred. One day ago, I suddenly felt dizzy and weak, and fainted twice while going to the toilet at night. The first time I fainted while urinating. About an hour later, I had to help my family to relieve my bowels again. After I finished defecating, I fainted again, about two minutes later. Wake up.

(Syncope is mainly related to defecation) 3. Past history: I have a history of hypertension for more than 10 years, 190/110mmHg; I was hospitalized in our department 20 days ago because my blood pressure was significantly elevated. Obvious abnormalities are seen. There was no history of syncope in the past. 4. Physical examination: P: 98 beats/min, BP: 130/90mmHg, conscious, heart rate: 98 beats/min, premature beats audible; pathological reflexes were not elicited. Diagnosis:

1. Cause of syncope: micturition syncope?

2. Hypertension level 3

3. Coronary heart disease? The main symptom now is syncope.

The main task is to find the cause of syncope; the characteristics of this patient's syncope:

1. Elderly male

2. There is a history of hypertension and arrhythmia. Before the onset of syncope, the symptoms of palpitations (premature ventricular contractions) were significantly aggravated.

3. The syncope attack is related to defecation, and the syncope attack occurs after defecation. They occur when urinating in an upright position or using support to defecate. During the attack, there were no convulsions and incontinence of urine and feces. After a few minutes, the pain will subside on its own after lying down.

4. After the syncope attack, the blood pressure measured at admission was 130/90mmHg. It was significantly lower than the previous basic blood pressure.

5. Brain CT is negative. No neurological signs. Characteristics of urinary syncope:

1. It mostly occurs in healthy men, but it is also more common in elderly men with various diseases.

2. It usually occurs during urination (defecation). Or immediately after urination (defecation)

3. Causes: fatigue, eating less, infection, etc. Mechanism:

During/after urination, the bladder suddenly decompresses, and the bladder mechanoreceptors are involved. , the vagus nerve is excited, the heart rate slows down, and the blood pressure decreases;

During/after defecation, the intestinal wall tension receptors are excited, which also excites the vagus nerve

Even when swallowing and coughing, the mechanism is similar.

The last are related tests that may excite the vagus nerve and need to be improved:

1. Dynamic electrocardiogram

2. Upright tilt test treatment:

1. Control blood pressure

2. Add Beta receptor blockers.

I agree with fenggan’s opinion.

I suspect it is micturition syncope.

I have seen several such patients and could not find any other cause of syncope.

1. Diagnostic ideas:

First look for the causes of syncope, 1. Reflex syncope; 2. Cardiogenic syncope; 3. Cerebral syncope, etc. The patient is urinating. Syncope occurs, so urinary syncope is possible, which is category 1. The patient has a history of palpitations, so cardiogenic syncope may be more likely. The patient has a history of hypertension, and the systolic blood pressure has reached 190, so TIA is possible.

2. Next step of diagnosis and examination:

First of all, carefully collect the medical history. For example, is there any rotation of vision when dizziness occurs? If so, if it can be alleviated by closing the eyes, then The brain source is more likely. If you only faint but not faint, the cardiogenic and reflex causes are more likely. Measure the blood pressure of both upper limbs. If the arteries steal blood, there will be a difference between the two sides.

Examination: 1) Routine blood test, routine urine test, and routine stool test to rule out anemic syncope, hypoglycemic syncope, etc. 2) Table exercise (excluding inertia disease), the patient has had palpitations for 7 years, and has chest tightness and pain after no activity, so CHD is basically not considered first. 3) Dynamic electrocardiogram (preferably done continuously for 48 hours) mainly excludes fast and slow syndrome. 4) Bedside electrocardiogram, the patient’s heart rate is 98 beats, analyze the type of tachycardia, whether there are premature ventricular contractions, or atrial fibrillation. 5) Brain MRI to rule out microscopic lesions such as lacunar cerebral infarction, 6) TCD, and B-ultrasound of the internal carotid artery and vertebral artery to check for flow velocity changes, stenosis or insufficient blood supply, and rule out the possibility of TIA. 7) Biochemistry and double renal artery B-ultrasound to identify primary and secondary hypertension.

Possible diagnoses: 1. TIA caused by atrial fibrillation, microemboli or other causes.

2. Fast-slow syndrome.

3. Arrhythmia, frequent premature beats, or common micturition syncope.

4. Chronic anemia.

Analyze the possible causes of syncope

1. I have seen a case report of pheochromocytoma (in the bladder). The blood pressure increased during urination and syncope occurred. Although the blood pressure in this patient was high, But if there are no other symptoms, hematuria and metanephrine screening can be tested. However, the patient has had high blood pressure for many years and has not had similar episodes in the past, so it is not very similar.

2. Vasovagal syncope. Tilt test can screen.

Situational syncope, urination (after urination): especially both occurrences during urination.

3. Arrhythmia (I suffer from frequent premature ventricular arrhythmias, so I need to pay attention to rapid ventricular arrhythmias and perform a 24-hour dynamic electrocardiogram)

4. Acute myocardial infarction/deficiency Blood: electrocardiogram, troponin quantification

5. Acute arterial dissection: the patient had high blood pressure for many years but was normal when admitted to the hospital. Echocardiogram 6. Pulmonary embolism/pulmonary hypertension

7. Cerebrovascular disease: Head CT scan: Due to a significant increase in blood pressure 20 days ago, the electrocardiogram showed frequent ventricular premature ejaculation, and the head CT showed no obvious abnormalities. Can be reviewed.

8. Metabolic disorders, including hypoglycemia, hypoxia, and hyperventilation with hypocapnia (not currently supported)

9. Orthostatic hypotension

1. An elderly man suffered from recurring palpitations for 7 years, which worsened and was accompanied by dizziness and fatigue and syncope twice a day. He had a history of hypertension and frequent ventricular premature ejaculation in the past.

2. The patient's two episodes of syncope occurred during sudden drops in abdominal pressure. Although he was 63 years old, he still considered vasovagal syncope---urinary syncope first. Then there's TIA.

3. But do some tests to rule out some diseases: do a dynamic electrocardiogram to rule out serious arrhythmias such as Aspen syndrome. The patient has had hypertension for 10 years and is highly suspected of having arteriosclerosis. TIA cannot be ruled out due to vascular stenosis. It is recommended to undergo carotid artery color ultrasound and transcranial Doppler. Check blood biochemistry to understand electrolyte status. Check the head CT to see if there is any space occupied.

Just check the main ones. In reality, not every person with the disease will agree to do all the tests.

Case characteristics:

1. Elderly male with long course of disease and acute onset/exacerbation

2. The main clinical manifestations are palpitations and syncope

3. Physical examination showed a small heart, irregular heartbeat, and a fast heart rate

4. EKG confirmed frequent ventricular premature disease

Frequent ventricular premature disease is more common in organic heart diseases such as coronary heart disease, cardiomyopathy, rheumatic heart disease, etc. Functional ventricular premature disease is also not uncommon, but considering that the patient is an elderly male, She has a long-term history of hypertension, and combined with the remaining medical history, it is believed that coronary heart disease is the first cause of palpitations, but organic heart disease caused by other factors (such as hypothyroidism) cannot be ruled out.

Syncope can be caused by vagal tone/vasodecompressive factors, cardiogenic factors, postural changes, cerebrovascular diseases and other factors. The patient can be in either the standing position (to relieve urination) or the squatting position (to relieve defecation). There is a syncope attack, and vasodepressor factors are more common in young patients. Combined with the history of basic cardiovascular diseases of the above-mentioned patients, the possibility of syncope caused by cardiogenic factors (arrhythmia?) is considered, and TIA cannot be ruled out (normal head CT can rule out TIA ?). In addition, the patient's new syncope only occurred for one day, and the two syncopes occurred at the same time period. It cannot be ruled out that it was caused by electrolyte imbalance, hypoglycemia, drug-induced hypotension (the patient had a history of taking the short-acting antihypertensive drug nitrendipine), etc. .

Therefore, preliminary diagnosis:

Cause of heart palpitations: possible coronary heart disease, sick sinus syndrome?

Hypertension grade 3

Remaining questions:

1. Questioning the medical history: According to the description of the current medical history, there is no evidence that the palpitations are "aggravated" - are there any palpitations before the onset of dizziness, fatigue, and syncope? (If there are symptoms of "exacerbation" of palpitations, consider that syncope is related to arrhythmia) What was the specific time of syncope attack? (Was the nighttime defecation before dinner time? The possibility of hypoglycemia cannot be ruled out.) Did you take other drugs such as nitrendipine before the syncope attack? (Blood pressure and hypoglycemic drugs may cause syncope attacks!) Do you have a history of diabetes?

2. Careful physical examination: The values ??of P and R seem to be reversed.

The heart is not big (a history of grade 3 hypertension for more than 10 years without target organ damage, the blood pressure lowering effect should be good, but why was he hospitalized due to high blood pressure 20 days ago? I still have a question)

3 . Complete auxiliary examinations: blood routine, stool routine OB, electrolytes, ECG/holter, blood sugar, T3 T4 TSH. If necessary, perform CAG and intracardiac electrophysiological examination to confirm the diagnosis.

1. Diagnostic ideas: 1. The patient has had recurrent palpitations for 7 years, which worsened after exercise, indicating that the palpitations may be related to high catecholamine levels during exercise or myocardial ischemia during exercise. 2. The main symptoms this time were dizziness, fatigue and fainting twice a day. Dizziness and fatigue indicate that the patient may have hypoperfusion or hypoxia (anemia) in the brain and skeletal muscles. The former may be related to too rapid and too rapid blood pressure reduction during admission, especially the use of calcium antagonists; the latter needs to be confirmed by examination. The two episodes of syncope were both at night, related to defecation, and inconsistent with the characteristics of the previous complaint of palpitations (related to activity), so the correlation between the two is small, but it cannot be ruled out that the arrhythmia has qualitatively changed, so HOLTER is indispensable; it is more likely that Orthostatic hypotension caused by antihypertensive drugs and the vagus reflex caused by defecation. The baroreflex of the elderly is already insensitive. If Betaloc and the like are used, it can suppress the already slow baroreflex and promote syncope. 3. The patient had no neurological symptoms or signs, and the syncope was not when he got up, so I think TIA is unlikely. 4. The patient's HR was too fast at 98bpm, and she had palpitations and high blood pressure. I remember there was a post in the forum saying that pheochromocytoma with ectopic bladder can cause micturition syncope, and another post said that medullary thyroid cancer is easily combined with pheochromocytoma. If the patient is not poor, you can consider checking it. Who makes the medical environment so bad? It is better to kill by mistake than to miss it. But I think if it is pheochromocytoma with ectopic bladder, there is no reason why urinating during the day will cause trouble at night, so The least likely, I ranked last.

Second, examinations should be completed: first, immediate and delayed blood pressure monitoring in lying and standing positions; 12-lead ECG; 24-hour blood pressure and ECG monitoring; routine blood test, fecal occult blood (now the specificity is high, The influence of meals can be ruled out); cervical arteries (including vertebral arteries) and cardiac ultrasound; chest X-ray. Let’s wait for other inspections to come out before these data come out!

Third, the diagnosis is mainly about syncope to be investigated. Please refer to the diagnostic ideas for possible causes.

I consider: 1. The possibility of cardiogenicity is high, as the palpitations have been recurring for seven years, worsening with dizziness and fatigue, and syncope twice a day. I have a history of coronary heart disease for seven years and an elderly person who has had high blood pressure for 10 years. An ECG done 20 days ago showed that ventricular premature ejaculation occurs frequently. There were occasional premature beats during this physical examination. Therefore, cardiac insufficiency of blood supply to the brain should be considered. At the same time, please pay attention to whether the patient has a history of diabetes, because when diabetic patients have a myocardial infarction, it appears as a painless myocardial infarction.

2. TIA, basis: elderly people with a history of hypertension for 10 years may experience transient insufficient blood supply to the internal carotid artery and transient syncope, but generally there will be no sequelae.

3. Vasovagal syncope, both times were related to posture, such as standing or squatting, so it should be ruled out, but it cannot explain the dizziness, fatigue, and inability to stand after waking up. symptom.

Therefore, I suggest that the patient should undergo the following examinations: 24-hour dynamic electrocardiogram, cardiac color ultrasound, transcranial Doppler, tilt test, etc., and then check the liver and kidney function to prepare for medication.

This case is relatively simple, but very subtle and interesting. When the truth comes out in the end, everyone will understand. The comrades upstairs analyzed it very comprehensively, but not many really considered it comprehensively. I also almost missed the diagnosis. , I would like to share it with you here. I hope more comrades can participate in it. Haha, it is more difficult for cases with few positive signs, not to mention the investigation of the cause of syncope. Generally, the net is cast widely. Now we provide the part of emergency investigation after admission. material.

1. Head CT: multiple lacunar cerebral infarcts in the basal ganglia on both sides 2. Blood picture: wbc: 13.2X109/L, Hgb110g/L 3. Normal electrolytes, renal function: BUN: 30.1mmol/L, CR: 126umol/L 4. , Electrocardiogram: Deep and large Q waves can be seen in II, III, and aF. Considering the inferior wall myocardial infarction, the truth seems to be clear about the occasional ventricular premature. Let us think about it carefully and try to explain its rationality.

Syncope in the elderly should be considered:

1. Drug-induced

2. Orthostatic

3. Carotid sinus allergy

4. If there are diseases and symptoms of the cardiovascular system, CAD, AB, SSS and ventricular arrhythmia should also be considered. As far as this patient is concerned, drug-induced syncope and orthostatic syncope cannot be ruled out, but I am more inclined to diseases of the cardiovascular system, such as coronary heart disease and hypertrophic cardiomyopathy.

The reasons for suspecting coronary heart disease are as follows:

1. Elderly

2. Male

3. Many years of history of hypertension

4. Recurrent palpitations for 7 years, worsening with dizziness and fatigue, and syncope twice a day

In fact, clinically there are certain patients with coronary heart disease who do not have obvious symptoms of angina or chest tightness. Instead, it presents as a substitute for angina pectoris, such as dyspnea, fatigue, abdominal pain, sweating, arrhythmia, syncope and other symptoms. This patient has multiple risk factors for coronary heart disease. The electrocardiogram has shown frequent ventricular premature ejaculation, and he is now experiencing syncope during defecation. We know that defecation can cause an increase in myocardial oxygen demand, thereby causing myocardial ischemia, angina pectoris, or acute myocardial infarction. This may The patient's syncope occurred without chest pain manifesting.

Of course, if coronary artery sclerosis is suspected, there may also be insufficient blood supply to the brain caused by cerebral arteriosclerosis. Hypertrophic cardiomyopathy is suspected because it causes syncope during postural changes, such as rising from a squatting position and when holding one's breath. I once cared for a 52-year-old female patient who had high blood pressure for many years and felt palpitation after exertion. I initially suspected coronary heart disease, but later B-ultrasound and cardiac catheterization confirmed that there was no problem with the coronary arteries and that she had hypertrophic cardiomyopathy. The patient's heart rate is fast, which may be caused by the reflex increase in heart rate caused by taking CCB drugs, but it does not rule out the possibility that the patient has insufficient blood volume (even if BP is normal) or anemia. My diagnosis:

1. Syncope to be investigated: cardiogenic disease is likely

2. Hypertension grade 3, extremely high risk, examinations that should be done:

1. ECG: Understand whether the patient has conduction system disease and myocardial ischemia. However, for angina pectoris, the positive rate of ECG is only about 50%.

2. Echocardiography: Understand the size of the heart chambers, thickness of the ventricular walls, valve conditions, and heart function.

3. Two-dimensional radiographs of the heart to understand the overall shape of the heart.

4. An exercise test needs to be done, and if necessary, coronary angiography can be done.

Of course, the three major conventions are indispensable. The moment I posted the post, the poster had already posted the answer.

Based on the information added by the poster, let me say a few more words!

The patient has had high blood pressure for many years. The patient’s blood pressure increased significantly 20 days ago. I don’t know if he had a headache at that time. We know that abnormal fluctuations in blood pressure can easily lead to cerebrovascular accidents. The occurrence of cerebrovascular accidents can also lead to abnormal increases in blood pressure. It is speculated that lacunar infarction may have occurred 20 days ago, but it was not found in the blind area of ??CT examination in the early stage. From the new information given by the poster, we learned that the patient's various target organs: heart, kidney, and brain have been damaged to a certain extent. A fundus examination is also required to understand the damage to the eyes. In patients with inferior wall myocardial infarction, a right heart lead electrocardiogram should be performed to understand whether there is right ventricular myocardial infarction. Because there are certain differences in the treatment of right ventricular myocardial infarction and left ventricular myocardial infarction, and right ventricular myocardial infarction can easily involve the cardiac conduction system, causing AB and ventricular arrhythmias. If so, the patient's syncope can be well explained. Right ventricular myocardial infarction can cause poor right heart circulation function - reduced blood pumping into the lungs - and reduced blood return to the left heart - easily leading to syncope.

1. When the patient exerts force to defecate, the intrathoracic pressure increases and the amount of blood returned to the heart from the systemic circulation decreases, which can lead to lowered blood pressure and even amaurosis and syncope;

2. When the patient passes the stool When standing up from a squatting position, blood stays in the lower limbs, which also reduces the amount of blood returned to the heart and can also cause syncope;

3. Arrhythmias occur when the patient defecates, such as II degree AB, short burst Ventricular tachycardia, etc., causing syncope in patients.

An elderly male patient suffered from recurring palpitations for 7 years, which worsened and was accompanied by dizziness and fatigue and syncope twice a day. He had a history of hypertension for 10 years. First of all, consider the target organ damage caused by high blood pressure, heart disease causing palpitations, heart disease causing cardiogenic cerebral insufficiency, electrocardiogram examination, dynamic electrocardiogram examination, and cardiac color ultrasound examination. It is clear that cerebrovascular disease caused by high blood pressure can cause dizziness, Fainting, etc. can be confirmed by head CT examination. Kidney damage can cause anemia, fatigue and other symptoms. 1. Head CT: multiple lacunar cerebral infarcts in the basal ganglia on both sides 2. Blood picture: wbc: 13.2X109/L, Hgb110g/L 3. Normal electrolytes, renal function: BUN: 30.1mmol/L, CR: 126umol/L 4. . Electrocardiogram: Deep and large Q waves can be seen in II, III, and aF. Consider inferior wall myocardial infarction and occasional premature ventricular disease. A high blood count may be caused by myocardial infarction, an increase in urea nitrogen, and a low hgb may be caused by benign renal arteriosclerosis caused by hypertension. Inferior wall myocardial infarction is prone to atrioventricular block, which may be accompanied by symptoms such as palpitations, dizziness, and fatigue.

Checking the cause of syncope is a troublesome matter. Regarding this case

1. This patient had frequent premature ventricular episodes in the past dynamic electrocardiogram, and syncope caused by malignant ventricular arrhythmia needs to be highly suspected. There can be many causes of ventricular premature disease. Deep and large Q waves can be seen in II, III, and aF of this patient. At least it is not a recent myocardial infarction. However, the elderly patient has a history of hypertension and electrocardiographic manifestations of myocardial infarction, indicating that coronary heart disease cannot be excluded. In some patients, angina pectoris attacks are characterized by arrhythmia, especially ventricular arrhythmia, and even sudden death from ventricular fibrillation.

2. The patient’s blood pressure level was once very high, and CT showed multiple lacunar infarcts in the bilateral basal ganglia, which could not completely rule out TIA attacks.

3. Syncope caused by structural abnormalities of the heart, including valvular disease, hypertrophic obstructive cardiomyopathy, etc. These diseases generally have typical murmurs, but this patient did not. Ignore it for the time being, and the heart ultrasound can be simple clear.

4. Patients should further consider CAG. If multiple tests still cannot clarify the cause of syncope, electrophysiological examination can be considered because the patient has clues about ventricular arrhythmia.