# Vasovagal Syncope With Sinus Arrest Triggered by Venipuncture in a Patient Receiving Multiple Psychotropic Medications: A Case Report

## TL;DR

A patient on multiple psychotropic medications experienced severe vasovagal syncope during a routine medical procedure, highlighting the risks and potential early warning signs.

## Contribution

This case report demonstrates how psychotropic medications can lower the threshold for severe vasovagal syncope and suggests BIS monitoring may detect early signs.

## Key findings

- A patient on multiple psychotropic medications developed sinus arrest during venipuncture.
- Bispectral index (BIS) values declined before bradycardia and hypotension, indicating early CNS involvement.
- Ephedrine administration restored hemodynamic stability after atropine failed.

## Abstract

Vasovagal syncope (VVS) is commonly described as the most frequent form of reflex syncope and is often regarded as benign. However, in some cases, VVS may progress to profound circulatory collapse with sinus arrest or even cardiac arrest, necessitating resuscitation. Previous reports have indicated that the concomitant use of multiple psychotropic medications, particularly antipsychotic agents, may influence autonomic regulation and hemodynamic stability, potentially lowering the threshold for VVS. As a result, even minor procedural stimuli can precipitate severe VVS in susceptible individuals.

A 29-year-old man with a history of anxiety, depression, and insomnia was receiving duloxetine, quetiapine, and several hypnotic agents and was scheduled for third molar extraction under general anesthesia. During intravenous cannulation, progressive bradycardia culminated in sinus arrest. Chest compressions and administration of atropine restored spontaneous circulation and consciousness approximately 45 seconds later, although bradycardia persisted until hemodynamic stability was achieved following ephedrine administration. Notably, bispectral index (BIS) values declined before the onset of bradycardia and hypotension, suggesting early central nervous system involvement in the syncopal cascade.

This case highlights that in patients receiving multiple psychotropic agents, even minor procedures can precipitate severe VVS. Psychotropic medications may lower the syncope threshold, and BIS monitoring may help identify early changes indicative of impending events.