Convulsive Syncope Due to Complete Atrioventricular Block in a Remote Area: The Critical Role of Helicopter Emergency Medical Services

Background: Syncope in older adults is a frequent and diagnostically challenging presentation in prehospital emergency care, particularly in geographically remote areas with limited access to advanced cardiac services. While many syncopal episodes are benign, some are caused by life-threatening conduction disorders such as complete atrioventricular block (CAVB), which may manifest with seizure-like activity due to severe cerebral hypoperfusion. Case Presentation: We report the case of a 70-year-old man with a history of hypertension, residing in a remote rural area, who experienced a nocturnal tonic–clonic episode followed by recurrent loss of consciousness. Due to difficult ground access, a helicopter emergency medical service (HEMS) team was deployed. On arrival, the patient was hypotensive and severely bradycardic, with recurrent syncopal episodes. Electrocardiography (ECG) confirmed CAVB with a slow escape rhythm. Temporary transvenous pacing was initiated but required progressively higher output, up to approximately 80 mV, with intermittent loss of capture, indicating a high risk of pacing failure and asystole. The patient was transported by helicopter to a tertiary interventional cardiology center, where he experienced additional syncopal episodes before undergoing emergent implantation of a permanent single-chamber ventricular pacemaker (VVI). Permanent pacing resulted in immediate hemodynamic stabilization, and no further syncopal or seizure-like episodes were observed. Conclusions: In geriatric patients presenting with convulsive syncope, cardiac causes such as CAVB must be rapidly identified. Unstable temporary pacing with high capture thresholds represents a life-threatening condition requiring urgent permanent pacemaker implantation. HEMS plays a critical role in ensuring timely access to definitive cardiac care in geographically isolated regions.