Man with convulsive syncope

A 48-year-old male collapsed during a physical therapy session at a rehab facility. Bystanders reported the patient lost consciousness briefly with abnormal jerking movements, bowel incontinence, and returned to baseline within 1 minute. His recent medical history includes a right tibial fracture and ureterolithiasis requiring ureteral stenting. In the emergency department (ED), he was tachycardic but hemodynamically stable, with mildly elevated troponin and d-dimer levels.

Submassive pulmonary embolism (PE) was revealed by computed tomography (CT) pulmonary angiography (Figure 1). Despite hemodynamic stability, this patient displayed right heart strain findings on both electrocardiogram and CT scans, with mildly elevated cardiac biomarkers. These findings were concerning for severe thrombotic burden and the patient underwent urgent pulmonary thrombectomy (Figure 2). Much can be learned from this case. First, it highlights that not all that shakes are seizures. Myoclonic jerking, often seen in syncope patients, can often be mistaken for seizure activity by bystanders, leading to potential anchoring bias in ED diagnosis.¹ Second, syncope should not be viewed as a definitive diagnosis, but rather as a symptom. It is essential to remember that syncope can be the primary presenting symptom in severe conditions such as PE, ruptured ectopic pregnancies, abdominal aortic aneurysms, gastrointestinal bleeds, and acute myocardial infarctions.² Finally, in patients presenting with submassive PE, using simplified pulmonary embolism severity index (sPESI) scores >1 to identify high-risk PE patients, then strategically collaborating with your institution's PE rescue team can facilitate prompt clot removal (Figure 3).³ Recent pulmonary thrombectomy trials demonstrate reduction in mortality and long-term thrombotic burdens of PE.^{4, 5}

The authors declare no conflict of interest.