Preventing and Managing Vasovagal Syncope

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Useful Actions for the Vasovagal Patient

Most importantly, try to avoid it. Ask the patient if they have a history of vasovagal reactions. The room should not be too warm or humid. The patient should not be dehydrated, have an empty stomach, or have had recent prolonged standing. The patient should be sitting or lying down. Pain should be minimized as much as possible with appropriate anesthesia before and/or during the procedure. The patient should keep their eyes closed when possible or at least avoid seeing any blood or needle.

If the patient does experience a vasovagal reaction:

• Use an alcohol wipe under their nose if they are feeling woozy.
• Lay them down flat, remove the pillow, and bend their legs up.
• At the onset of prodromal symptoms, instruct them on counterpressure maneuvers, such as hand grip (or gripping a rubber ball) as hard as possible, leg crossing (while tensing the leg, abdominal, and gluteal muscles), or arm tensing (involving gripping one hand with the other while simultaneously moving both arms away from the body), which can delay or even prevent vasovagal syncope.
• Offer juice or a lollipop (only once they can sit up).
• Use an ice pack or ice-cold, wet towel on the face or back of the neck.

Benjamin Barankin, MD, FRCPC
Toronto, ON, Canada

Don’t Forget About Madelung Disease

A female patient presents with a recent increase in the circumference of her upper arms. She can no longer fit into her sleeved shirts. Her friends think she is lifting weights. Consider the diagnosis of Launois-Bensaude syndrome (Madelung disease) with diffuse increase in subcutaneous fat around the arms, neck, and shoulders. These patients frequently have alcohol use disorder; smoke cigarettes; and have abnormal liver function tests, hyperlipidemia, diabetes mellitus, hyperuricemia, and/or polyneuropathy. There is a metabolic defect in fatty tissue lipolysis. Diet and exercise are not effective in reducing the subcutaneous fat but improve the comorbidities. Surgical fat removal results are temporary, and the fat regrows. Importantly, these patients need to be comanaged by primary care and neurology.

Wayne Fujita, MD
Aiea, HI

Liquid Nitrogen for Port Wine Stains and Hemangiomas

Freeze the lesion with liquid nitrogen for a few seconds only, wait 30 seconds, and then freeze again for a few seconds more. Repeat this procedure 4 to 5 times at 5 to 6 visits and there will be no depigmentation. I have only used this method on the face.

Subrata Malakar, MD
Kolkata, India