CASE REPORT
Loss of Consciousness and Seizure During
Normobaric Hypoxia Training
Natalie C. Moniaga and Cheryl A. Griswold
MONIAGA NC, GRISWOLD CA. Loss of consciousness and seizure
during normobaric hypoxia training. Aviat Space Environ Med 2009;
80:485–8.
Loss of consciousness is a symptom with a broad differential diagno-
sis. Distinguishing between syncope and seizure in a patient with a his-
tory of loss of consciousness can be equally difficult as their presentation hypobaric exposure. Each student is continuously moni-
can be very similar. We present the case of a naval electronic counter-
measures officer who experienced a loss of consciousness while under-
going hypoxia training with the reduced oxygen breathing device
(ROBD). During the episode the patient experienced tonic-clonic con-
tractions with subsequent vertebral fractures, resulting by Ingentaloss
in a prolonged
Delivered
grounding period. The patient’s work-up focused on ruling out inherent
IP: 185.101.71.15 On: Sun,hypoxia
cardiac and neurologic etiologies. After extensive examination
Copyright: and con-
Aerospace
sultation with neurology, the patient was diagnosed with hypoxia-
induced seizure, but was not felt to have an underlying seizure disorder.
After reviewing his case, the Naval Aerospace Medical Institute felt that
this incident represented a physiologic event and not a medical condi-
tion inherent to the aviator. It was, therefore, determined that this epi-
sode was not considered disqualifying and did not require a waiver for
return to duties involving flight. Our discussion details the appropriate
work-up for loss of consciousness, examines possible physiologic expla-
nations for this event, and describes aeromedical considerations. The
authors include the patient’s physiology instructor, one of the primary
witnesses for the event, and the patient’s flight surgeon, who was exten-
sively involved in his care.
Keywords: mask-on hypoxia training, differential diagnosis of loss of
consciousness, oxygen paradox, risks of the reduced oxygen breathing
device.
H YPOXIA TRAINING IS an important aspect of avi-
ation survival training for military aviators. Stu-
dents learn first hand, under controlled conditions, the
general effects of hypoxia and its insidious nature. Hy-
poxia training allows students to experience the signs
and symptoms of hypoxia so that they can recognize an
extremis situation and conduct emergency procedures
as appropriate. In 2004 the U.S. Navy began to institute
normobaric or ground-level hypoxia training for tactical
jet refresher students using the reduced oxygen breath-
ing device (ROBD). The system works by delivering a
controlled mixture of O2 and N2 to the aviator’s mask,
thereby producing hypoxia to altitude equivalents up to
34,000 ft. The instructor selects a standardized training
profile with known ascent rates, altitudes, and descent
rates (2). The ROBD demonstrates the effect of hypoxia
on the individual and provides training on emergency
procedures for loss of cabin pressurization, malfunction-
ing oxygen equipment, and other emergencies that re-
quire supplemental or emergency oxygen (2).
The ROBD is considered low risk in comparison to the
low-pressure chamber where hypoxia demonstrations
Aviation, Space, and Environmental Medicine x Vol. 80, No. 5, Section I x May 2009
have historically occurred because the ROBD provides
a normobaric exposure to a level of hypoxia equivalent
to a selected altitude and, therefore, avoids the risk of
barotraumas and decompression sickness associated with
tored for oxygen saturation and heart rate during the
ROBD session by their personal instructor, further decreas-
ing risks. Here we present a case of hypoxia-induced
of consciousness
to: Guest User (LOC) while undergoing routine
26 Jun 2016 02:28:30
training on the ROBD.
Medical Association
CASE REPORT
A 31-yr-old Caucasian male electronic countermea-
sures officer presented to the emergency room after a
sudden episode of LOC and tonic-clonic contractions
while undergoing the second of two routine hypoxia
training sessions on the ROBD. The event was witnessed
by multiple staff members at the Aviation Survival
Training Center, including his training instructor, an
aerospace physiologist.
During his first training run (Table I), the patient de-
clared that he was feeling hypoxic and conducted his
aircraft-specific emergency procedures during the third
minute of the evolution and after 1 min at a simulated
altitude of 25,000 ft. At that time he was switched to
100% O2. The patient’s vital signs declined until reach-
ing an Spo2 of 69% and heart rate (HR) of 108. The
patient continued receiving 100% O2 until his Spo2 was
back up to his initial resting level and he reported feel-
ing normal. The instructor debriefed the patient, who
then expressed an interest in repeating the training, stat-
ing that he thought he was “sensitive to hypoxia” and
had recognized cabin pressurization problems in the air-
craft during squadron training flights several times be-
fore any other members of the aircrew. The second run
was to be conducted with the patient stating how he felt
From the Naval Hospital Oak Harbor, NAS Whidbey Island, and
the Aviation Survival Training Center, Whidbey Island, Oak Harbor,
WA.
This manuscript was received for review in July 2008. It was ac-
cepted for publication in January 2009.
Address reprint requests to: LT Natalie C. Moniaga, Aviation Medi-
cine, 3475 N. Saratoga St., Bldg. 993, Oak Harbor, WA 98278; natalie.
moniaga@med.navy.mil.
Reprint & Copyright © by the Aerospace Medical Association, Alex-
andria, VA.
DOI: 10.3357/ASEM.2397.2009
485
SEIZURE DURING HYPOXIA TRAINING—MONIAGA & GRISWOLD
TABLE I. ROBD RUN 1.

Lowest Values Seen After

Simulated Altitude Site Level 10 K’ at 2 min 25 K’ at 1 min Conducting EPs
%O2 delivered* 20.95% 14.08% 7.11% 100%
SpO2 98% 93% 92% 69%
HR 73 83 88 108

* Values courtesy of Environics, Tolland, CT.

and the instructor relaying the patient’s Spo2 and HR,
so that he could compare his physical symptoms to his
measured oxygen saturation.
On the second training run (Table II) the patient re-
ported air hunger after 1 min at a simulated altitude of
25,000 ft. After 3 min, the patient reported feeling sweaty
and tingling and began executing aircraft-specific emer-
gency procedures and was switched to 100% O2. A few
moments later, he slumped forward in his seat, uncon-
scious and non-responsive to pain via sternal rub. He
was noted to have a fixed gaze and myclonic jerks fol-
lowed by tonic spasm. The patient was kept on 100% O2
and remained unconscious for approximately 4 min.
Delivered by Ingentanitrogen,
When he regained consciousnessIP:he185.101.71.15
was immediately
On: Sun, 26 Jun 2016 white blood cell count. Electrocardiogram
alert to person, place, and situation, but exhibitedAerospace
Copyright: slurred
Medical
speech and complained of severe back pain. The patient
arrived in the Emergency Department approximately 10
min after the initiation of the incident and was alert and
oriented to person, place, time, and situation. He stated
that just prior to the LOC he felt extreme air hunger and
lightheadedness. He denied headache or aura prior to
the incident. His first memory after the event was awak-
ening with tongue pain, back pain, and a feeling of heavi-
ness in his head and extremities. He stated that he felt
confused initially, but only briefly.
Past medical history was significant only for muscu-
loskeletal injuries. The patient denied a past history of
seizure, intracranial infection, high fever, or symptoms
suggestive of brain tumor such as chronic headache or
visual changes. He did have a remote history of mild
concussion with LOC at age 5. The 72-h history revealed
that the patient received only 4 h of sleep the night be-
fore the event and averaged 4 h of sleep each night over
the last 72 h. He denied use of medications, supplements,
alcohol, or tobacco in the 72 h prior to the event. He
stated that his hydration status was normal and that
urine output and concentration appeared normal over
the last 72 h. Review of systems revealed severe back
pain localized to the thoracic spine, lateral tongue pain,
and nausea.
On examination vital signs were normal, with an
Spo2 99% on room air. The only significant findings
included tenderness to palpation over his thoracic spinous
processes and over the right scapula. Examination of the
oral cavity and pharynx revealed no abnormalities. There
was no obvious tongue injury noted. Cardiovascular and
neurologic examination, including cranial nerve testing,
strength testing, sensory testing, deep tendon reflexes,
and rapid alternating movements, were normal. The pa-
tient had a negative Babinski sign. Gait and balance were
normal. Labs, including magnesium, thyroid stimulating
hormone, calcium, glucose, creatinine, and blood urea
to: Guestwere
Usernormal. Complete blood count revealed
an elevated
02:28:30
(EKG) demonstrated
Association normal sinus rhythm. Computed
tomography (CT) of the head was normal. Radiographs
of the chest and thoracic spine showed compression frac-
tures of the 6th, 7th, and 8th thoracic vertebral bodies
likely secondary to his myoclonic jerks. CT of the tho-
racic spine demonstrated the same with no evidence of
cord impingement. Single photon emission computed
tomography of the thoracic spine demonstrated marked
tracer accumulation in the same vertebral bodies, which
is most consistent with an acute traumatic event.
After receiving pain control for his fractures he was
issued a grounding notice and discharged home. The
following day his only complaint was residual back pain.
He felt “100%” otherwise and stated that he was “ready
to get back to flying.” His white blood cell count by this
time had normalized. Neurologic examination remained
normal. Given the duration of his LOC and the severity
of his tetanic contractions, neurological consult was ob-
tained. Electroencephalogram (EEG) was normal on
two separate occasions. Magnetic resonance imaging
(MRI) of the brain was also normal, demonstrating no
masses and no vascular abnormalities. Given the pa-
tient’s benign history, his negative diagnostic workup,
and the presence of a known precipitating factor, the
opinion of the neurologist was that his history was
most consistent with seizure due to hypoxia and not a

TABLE II. ROBD RUN 2.

Lowest Values Seen

Simulated Altitude Site Level 10 K’ at 2 min 25 K’ at 1 min 25 K’ at 2 min 25 K’ at 3 min After Conducting EPs

%O2 delivered* 20.95% 14.08% 7.11% 7.11% 7.11% 100%

SpO2 98% 93% 85% 80% 77% †
HR 71 79 90 93 97 †

* Values courtesy of Environics, Tolland, CT.

†
Values not recorded as pulse oximeter was knocked loose during convulsions.

486 Aviation, Space, and Environmental Medicine x Vol. 80, No. 5, Section I x May 2009
SEIZURE DURING HYPOXIA TRAINING—MONIAGA & GRISWOLD
primary seizure disorder such as epilepsy. Of note, the
patient reported receiving only 4 h of sleep each of the
3 nights prior to the event. Sleep deprivation is known
to lower seizure threshold and was likely a contributing
factor. However, he has a long history of intermittent
sleep deprivation due to operational and training de-
mands. This was his first episode of seizure, which
would suggest that sleep deprivation alone was not a
sufficient precipitating factor and that the hypoxic envi-
ronment played a larger role in the event.
DISCUSSION
Hypoxic hypoxia was the leading suspected cause for
LOC and seizure in this electronic countermeasures offi-
cer with a benign history and an obvious provoking fac-
tor. However, in the general population LOC is a symptom
often posing a diagnostic dilemma with a wide differen-
tial diagnosis to be considered. The differential diagnosis
should generally be focused on two main organ systems:
cardiovascular and neurologic. Syncope is a symptom
characterized by a transient, self-limited loss of con-
sciousness with a relatively rapid onset Delivered by IngentaThis
and usually
IP: 185.101.71.15 On: Sun, 26 Jun 2016 02:28:30
leading to a fall. Subsequent recovery is spontaneous,
Copyright: Aerospace Medical Associationpatients with rare recurrent symptoms (6).
complete, and prompt. The underlying mechanism of
syncope is transient global cerebral hypoperfusion (3).
Seizure is the manifestation of a paroxysmal discharge of
abnormal rhythms in some part of the brain. Epilepsy is a
condition in which seizures recur, usually spontaneously
(3). The patient in this case had been subjected to reduced
oxygen breathing, producing a hypoxic state similar to
that experienced at altitude in an unpressurized environ-
ment. Hypoxia (and thus cerebral hypoperfusion) is a
known cause of syncope and non-epileptic seizure, and
the two diagnoses are often difficult to distinguish.
In patients who are severely hypoxic, re-oxygenation
does not immediately raise oxygen saturation, a phe-
nomenon referred to as oxygen paradox (5). On this pa-
tient’s first run in the ROBD his Spo2 continued to decline
after receiving 100% O2 and his HR continued to increase,
eventually reaching an Spo2 of 69% and HR of 108 before
subsequently improving. On his second run his LOC
and subsequent tetanic contractions resulted in inadver-
tent disconnection of his pulse oximeter, ergo we do not
have Spo2 data after the initiation of 100% O2. However,
if we assume a similar drop in his initial Spo2 with re-
oxygenation on his second run, this oxygen paradox
could likely have contributed to prolonging his period
of hypoxia.
As with all initial evaluations, neurologic work-up
should begin with a thorough history and physical ex-
amination. If seizure is suspected based on the patient’s
history, the next step is to obtain an EEG, the essential
study in the diagnostic evaluation of seizure. If abnormal,
it may aid in confirming the diagnosis. Sleep depriva-
tion, hyperventilation, and intermittent photic stimula-
tion increase yield. However, a normal EEG does not
rule out seizure and many EEG abnormalities are non-
specific (7). Neuroimaging should also be done to ex-
clude structural abnormalities. MRI is preferred over CT
Aviation, Space, and Environmental Medicine x Vol. 80, No. 5, Section I x May 2009
to identify specific lesions such as dysplasia, infarct, and
tumor. However, CT is suitable to exclude mass lesion,
hemorrhage, or large stroke in emergency situations (7).
As in this case, complete blood count will often demon-
strate an increase in white blood cell count in the acute
setting after a seizure; thus abnormal tests detected im-
mediately after the event should be repeated (7). Glucose,
calcium, magnesium, renal function tests, thyroid-
stimulating hormone, and toxicology should also be
done in the acute setting (7).
Other studies that should be considered in the work-
up of LOC include EKG to rule out ongoing arrhythmia
as a cause of cerebral hypoperfusion. If arrhythmia is
strongly suspected, continuous heart monitoring should
be performed in an attempt to record an infrequent ar-
rhythmia. Modalities to consider include the use of ex-
ternal monitoring devices such as a 24-h Holter monitor,
which records a continuous EKG for 24 h, or an event
monitor, which records information only when prompted
by the patient and can be used for many weeks to months.
If the arrhythmia is very infrequent an implantable loop
recorder can be inserted and left in place for up to 14 mo.
to: Guest
is the User
diagnostic test of choice to detect bradyar-
rhythmias in
Tilt-table testing and invasive electrophysiological stud-
ies may also be helpful (4,6).
The most common etiologies of syncope include vaso-
vagal/situational syncope, cardiac arrhythmias, and
orthostatic hypotension, though there is a wide range
of possible causes. In up to 39% of cases the cause is not
established (6). In this patient seizure was determined to
be the final diagnosis based on the clinical description of
the event, which was well described by numerous wit-
nesses, the presence of a known stimulus in conjunction
with a history of sleep deprivation, injury consisting of
vertebral compression fractures, a known presenting
feature of seizure (1), and a history and work-up incon-
sistent with cardiovascular syncope.
Thoracic fractures are considered disqualifying for duty
involving flight. Waiver will be considered for ejection-
seat aircraft so long as the patient remains asymptomatic
and there is no instability of the fractures (10). Multiple
compression fractures may increase the degree of post-
injury kyphosis, potentially limiting an aviator’s ability to
function in the cockpit. Therefore, a cockpit functionality
check is useful in evaluating an aviator’s ability to re-
turn to flight, which in this case demonstrated an aviator
able to function normally in the cockpit and to reach all
pertinent control surfaces in no discomfort while wearing
full flight gear.
The risk of seizure in flight is obvious. Incapacitation
is in most cases sudden, unpredictable, unavoidable, pro-
longed, complete, and potentially more frequent in the
stressful flying environment. This risk constitutes a di-
rect threat to the health and safety of self, others, and the
success of the mission (8,9). Given this aviator’s benign
medical history and the presence of two precipitating
factors, sleep deprivation and hypoxia, it was the opinion
of the neurologist that he does not have a primary seizure
disorder. After reviewing his case, the Naval Aerospace
487
SEIZURE DURING HYPOXIA TRAINING—MONIAGA & GRISWOLD

Medical Institute felt that this incident represented a Department of the Navy, Department of Defense, nor the U.S.
government.
physiologic event and not a medical condition inherent Authors and affiliations: LT Natalie C. Moniaga, M.D., B.A., Electronic
to the aviator. They, therefore, determined that this epi- Attack Squadron One Two Nine, NAS Whidbey Island, WA, and LT
sode was not considered disqualifying and did not re- Cheryl A. Griswold, M.E.S.S., B.S., Aviation Survival Training Center
quire a waiver for return to duties involving flight. He Whidbey Island, Oak Harbor, WA.
has since repeated his ROBD training successfully and
without incident and has returned to unrestricted duties REFERENCES
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involving flight. presenting feature of unrecognized epileptic seizures. Arch
When evaluating an aviator with a history of seizure Fam Med 1997; 6:185–7.
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of aeromedical disposition, including: the likelihood of tactical jet aviators: evaluation of an alternate instructional
paradigm. Aviat Space Environ Med 2006; 77:857–63.
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return to duties involving flight. The patient in this case Philadelphia, PA: Lippincott Williams & Wilkins; 2002:37.
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could be the case for a pilot in a single-seat aircraft. This 8. U.S. Air Force. Waiver guide: seizures/epilepsy/abnormal EEG.
case, while severe, was felt to be physiologic in nature Retrieved 20 April 2008 from https://kx.afms.mil/kxweb/
with a low risk of recurrence. Delivered by Ingenta to: Guest User
dotmil/kjFolderSearch.do?queryText 5waiverguideneurology
IP: 185.101.71.15 On: Sun, 26 Jun &functionalArea
2016 02:28:30 5WaiverGuide&folder5Waiver1Guide1-1
Copyright: Aerospace Medical Neurology .
Association
ACKNOWLEDGMENTS 9. U.S. Air Force. Waiver guide: syncope. Retrieved 20 April 2008
The authors would like to thank Dr. Henry Porter, flight surgeon, from https://kx.afms.mil/kxweb/dotmil/kjFolderSearch.do?
neurologist, and Director of Neurology at the Naval Aerospace Medical queryText5waiverguideneurology&functionalArea5Waiver
Institute, and LCDR Rich Folga, CAsP, Director, Human Performance Guide&folder5Waiver1Guide1-1Neurology.
& Training Technology Naval Survival Training Institute, for review- 10. U.S. Navy. Naval Operational Medicine Institute’s aeromedical
ing this manuscript and offering their thoughtful criticisms. reference and waiver guide: spinal fractures. Retrieved 20
The views expressed in this article are those of the authors April 2008 from http://navmedmpte.med.navy.mil/nomi/
and do not necessarily reflect the official policy or position of the nami/waiverguidetopics.cfm.

488 Aviation, Space, and Environmental Medicine x Vol. 80, No. 5, Section I x May 2009