1214 - Lemon Drop: A Bizarre Case of Frozen Lemonade Induced Syncope in SCI Patient

Thursday, February 22, 2024

5:00 PM – 6:30 PM EDT

Presenting Author(s)

ML

Matthew League, BS

Osteopathic Medical Student, IV
Lincoln Memorial University - DeBusk College of Osteopathic Medicine
Houston, Texas, United States

Co-Author(s)

MC

Morgan R. Cowan, DO

Resident Physician
University of Texas Health Science Center at Houston
Houston, Texas, United States
JT

Judy L. Thomas, MD

Attending Physician
UT Health McGovern School of Medicine Clinical Assistant Professor PM&R department, Chief of PM&R, Lyndon Baines Johnson Hospital
Houston, Texas, United States

Case Diagnosis: Vasovagal syncope, Dysautonomia in SCI

Case Description: A previously healthy 26-year-old male was admitted to inpatient rehab due to a C5 ASIA-C spinal cord injury (SCI) caused by a gunshot wound. Post-injury, he experienced autonomic dysfunction, including orthostatic hypotension and temperature regulation issues. Five weeks post-injury, he experienced a syncopal episode after consuming two sips of frozen lemonade. He regained consciousness after 30 seconds, with no recollection of the events immediately before or after losing consciousness. Nursing staff found him alert and oriented. Six hours prior to the episode, his blood pressure (BP) was 104/67 mmHg and pulse rate (PR) was 86 beats per minute (bpm). Two minutes post-episode, BP was 89/52 mmHg and PR was 87 bpm. Fifteen minutes after, BP was 126/90 mmHg and PR was 72 bpm. The episode was attributed to SCI-related neurocardiogenic autonomic dysfunction. Treatment included an abdominal binder, compression stockings, and midodrine, successfully preventing further syncopal episodes.

Discussions: Neurocardiogenic autonomic dysfunction often accompanies cervical and upper thoracic spinal cord injury (SCI). Disrupted cardiovascular-regulating descending spinal pathways contribute to unopposed vagal parasympathetic control and blunted sympathetic activity. This autonomic state favors decreased venous vascular tone leading to peripheral blood pooling reducing preload, diminished cardiac contractility reducing afterload, and decreased circulating catecholamines leading to upregulation of adrenergic receptors and heightening of reflex sympathetic activity. Within this physiological context, we propose that even milder vagal stimuli, like pharyngeal cooling from cold beverages, can provoke syncope.

Conclusions: Vasovagal syncope triggered by cold beverage swallow is a sparsely documented phenomenon that poses potential hindrance to completing therapy and safety risks in the dysautonomic SCI patient. SCI providers, patients, and their families should be educated and aware of the autonomic changes, including vasovagal syncope, that may be experienced after SCI for diagnostic and management purposes.