What are the key points for a paramedic (Emergency Medical Technician - EMT) to know when treating a patient with suspected Brugada syndrome?

Key Points for Paramedics Treating Suspected Brugada Syndrome

If you suspect Brugada syndrome in the field, your primary goals are to recognize the ECG pattern, avoid dangerous medications, aggressively treat fever, and prepare for life-threatening ventricular arrhythmias that require immediate defibrillation.

Recognizing Brugada Syndrome

ECG Pattern Recognition

• Look for the Type 1 Brugada pattern: coved ST-segment elevation ≥2 mm in leads V1 and/or V2 with negative T-waves 1, 2
• This pattern may appear intermittently or only during certain triggers—a normal ECG doesn't rule it out 2
• Try high electrode positioning in the 2nd and 3rd intercostal spaces for V1-V2 to improve detection 3, 2
• The ECG pattern can fluctuate between normal and abnormal, so serial ECGs are valuable if time permits 2

Patient Demographics

• Predominantly affects males (90% of diagnosed cases) in their 30s-40s, though it can occur at any age 1
• More common in Southeast Asian populations 1
• Events typically occur at rest or during sleep 1, 4

Critical Triggers to Identify

Fever is Extremely Dangerous

• Fever is a major trigger for cardiac arrest in Brugada patients and can unmask the ECG pattern 1, 3, 2
• Aggressively treat any fever with antipyretics immediately—this is potentially life-saving 1, 3, 2

Other Important Triggers

• Excessive alcohol intake can precipitate arrhythmias 1, 3, 2
• Cocaine use is a known trigger 1, 3, 2
• Large meals may provoke events 1, 2
• Certain psychotropic medications and anesthetic agents 1, 3, 2

Medications to AVOID

Dangerous Drug Classes

• Sodium channel blockers (can worsen the condition and trigger arrhythmias) 1, 2
• QT-prolonging medications 3
• Specific drugs to avoid include certain antiarrhythmics, psychotropics, and anesthetics 1, 3
• Reference www.brugadadrugs.org for a comprehensive list 1

Arrhythmia Management

Expected Arrhythmias

• Polymorphic ventricular tachycardia (VT) or ventricular fibrillation (VF) are the life-threatening rhythms 1, 4
• These can occur suddenly, even in previously asymptomatic patients 1

Treatment Approach

• Standard ACLS protocols apply: immediate defibrillation for VF/pulseless VT 1
• Isoproterenol may be beneficial for electrical storm (recurrent VT/VF) if available and within your scope 1
• Transport rapidly to a facility capable of advanced cardiac care and ICD placement 1

Risk Stratification for Transport Priority

Highest Risk Patients (Immediate Transport)

• Cardiac arrest survivors (13.5% annual event rate) 1, 3
• Patients with syncope and spontaneous Type 1 ECG pattern (3.2% annual event rate, 6-fold higher risk than asymptomatic) 1, 3, 2
• Spontaneous Type 1 pattern carries worse prognosis than drug-induced pattern 2

Lower Risk (Still Requires Evaluation)

• Asymptomatic patients with Type 1 pattern (1% annual event rate) 1, 3
• Patients with only drug-induced patterns have low immediate risk 2

Scene Assessment and History

Key Questions to Ask

• Recent fever or illness? (critical trigger) 1, 3
• Family history of sudden cardiac death, especially in young relatives? 1, 3
• Previous syncope or seizure-like episodes? 1, 3
• Recent alcohol consumption or drug use? 1, 3
• Known diagnosis of Brugada syndrome or ICD in place? 1

Physical Examination Findings

• Structurally normal heart—no murmurs or abnormal findings expected 1, 5
• If patient has ICD, check for recent shocks (patient may report them) 1

Transport and Communication

Hospital Notification

• Alert receiving facility of suspected Brugada syndrome with high-risk features 1
• Emphasize need for cardiology consultation and potential ICD placement 1
• Communicate any identified triggers (fever, drugs, alcohol) 1, 3

Family Considerations

• First-degree relatives are at risk and need screening 3, 2
• Document family history of sudden death for hospital team 1, 3

Common Pitfalls to Avoid

• Don't assume a normal ECG rules out Brugada—the pattern is intermittent 2
• Don't give sodium channel blocking antiarrhythmics (like procainamide or flecainide) 1, 2
• Don't delay fever treatment—even mild fever is dangerous 1, 3
• Don't dismiss syncope as "just a faint" in young males with this ECG pattern 1, 3, 2
• Don't overlook the diagnosis in females—though less common, it still occurs 1