In the last Friday a patient was brought to my ER from the airport. He was previously reported by the control point as a cerebral commotio. He was a man in the 4 decade who flew from a big city in the USA to Europe accompanied by his wife. It was interesting that he is a nephrologist and his wife is a general surgeon.The man could not give much information because he felt quite weak. His wife told me that he took some sleeping pils at the beginning of the flight and slept for several hours. Now and then he complained about some epigastrial pain. He went to the toilette and came not back, so his wife went to look for him. She found him fallen in front of the toilette door with some afraid people around. After this he had several seizures and the doctor who brought him from the airport reported some more seizures. The clinical examination showed some abdominal pain without any neurological findings.
On the suspicion for a internal cerebral bleeding, we performed an immediate cranial CT, which showed no pathological findings. Because of the epigastrial pain we assumed, he could have a posterior MI. But the ECG and labs was normal except some elevated WBC of 10.4 Bil/l without elevation of the CRP.
We began the monitoring and then he suddenly started vomiting and got asystolic for 15 seconds. I organized a spot in the ICU and took him there. At the arriving in the ICU he got once again such a vaso-vagal syncope. At the other time he was normal responsive and felt weak. About an hour after the admission he expressed some pain in the right lower quadrant. A repeated abdominal examination showed some tenderness there. We decided to make a laparoscopy, which showed the acute appendicitis. The appendix could be easily removed laparoscopically.
The patient was brought to a normal ward and could be dismissed 2 days later in a good condition.
I discussed the reported seizures with the wife of the patient. She is a general surgeon for some 20 years . Her point of view was that the combination of the sleeping pill, the orthostatic situation after standing up after a long flight in the economy class and the acute inflammation could explain the fall and the choking was taken for a seizure, as there were no previous neurological history.
Conclusion: Not every reported cerebral commotio could be leaved without an appendectomy. :)
Randy | 03-Jun-09 at 12:48 pm | Permalink
This week during sleep, I have had two incidents of choking and while I sat up in bed immediately to try and catch my breath I experienced what I thought was a vaso vagular. I passed out on the floor and hit my head against my wall and nightstand. This has happened two times this week and I am sfraid. I have had a vaso vagular before. What to do?
Ivo Mitsiev | 05-Jun-09 at 9:51 pm | Permalink
Randy, first thank you for stopping by! :)
Your problem may be a vaso-vagal syncope but you would probably understand that it is impossible to make a good diagnosis with this kind of communication. There could be also other reasons for this kind of symptoms and therefore you should see a doctor who would take care.
I generally suggest seeking initial help at the Primary Care Doctor. She or he would refer you to a specialist if this is necessary.
Last but not least, I am a surgeon. In the surgery, we don’t have so much to do with vaso-vagal problems or reasons for fainting unless there is a clear underlying vessel problem which could be surgically repaired.
You are actually in a healthcare oriented college, so it shouldn’t be difficult to find a good doctor who would address your problem.
I hope to have been able to help you.
Best wishes and good luck! :)