Download Interesting Case Rounds

Interesting Case Rounds
Mark Boyko
EM Resident
REDIS ‘Reason For Visit’
“Penis caught in the net”
CASE
• 30-year old middle-eastern woman presents to the
ER with complaints of a bilateral, throbbing
headache, located in the occipital region.
• “Heart rate 34” on REDIS.
• Stable when you see her
• Difficult history because of language barrier. Baby
is present in stroller by bed.
CASE
• VITALS:
HR 34, regular
BP 170/105 right arm
RR 18
O2 96% on RA
Temp 37.3
CASE
• It came on gradually 2 days earlier, was 10/10 but now is 8/10.
• Unresponsive to Tylenol, worried about taking anything else
because she’s breastfeeding.
• No visual changes, no photophobia, no dizziness
• Has some neck stiffness, has been nauseated but has not
vomited
• H/A worse when she lies down, has not been able to sleep
• Has not been very mobile since delivery, still quite sore in the
abdomen
• Denies chest pain, dizziness, shortness of breath
• Denies bleeding per vagina
• “Please just make the headache stop”
Past Med Hx
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Born in Saudi Arabia
Denies any medical conditions
Denies previous heart problem
Mostly inactive
No medications
No drugs/EtOH
Pregnancy Hx
• First baby, no previous pregnancy
• Spent first 6 months of pregnancy in Saudi Arabia, then moved
to Canada
• Denies any complications during pregnancy
• Blood pressure was always “low”
• Carried baby ~40 weeks, delivered at PLC
• SROM but failed to dilate beyond 5cm, was taken for c-section,
baby was out under 24hrs from ROM. No fever for mom or baby
• Had epidural but “took them a few tries, it was painful near my
lower back”
• Stayed in hospital 4 days, “they were checking out my heart”
Phx
HR fluctuating between 32-40 BPM
General: Sweaty, but A/O
CNS:
PERL, EOM normal, fields normal
able to flex/extend neck, not objectively stiff
no pronator drift
symmetrical movements UL & LL, power 5
reflexes 1 in UL & LL
Phx (cont)
CVS:
JVP not elevated
N S1 S2, II/VI mid-systolic murmur LUSB
pulses equal R & L radial
RESP:
normal A/E, equal, no crackles
ABDOMEN:
incision looks okay
bulky mass left side of midline just above incision, very tender
Otherwise no peritoneal signs
BACK:
4 puncture wounds near site of epidural, tender near area, no cellulitis or
mass
LEGS:
no calf tenderness or swelling
pedal pulses present
Thoughts So Far?
About that heart rate…
Blood Work
Na+ 142
K+ 3.8
Cl- 105
HCO3- 2.3
WBC 8.0
Hgb 143
Plts 211
Hct 0.45
Glucose 7.6
Cr 50
BUN 3.1
Old Charts Come Down…
• Cardiology saw her post-op day 1 after
nurse noticed “low HR in the morning”, and
ECG showed 2nd degree heart block Mobitz
II
• Holter done, ‘untypable’ 2nd degree block
possibly Mobitz I
• ECHO was done, results normal
• discharged home with follow-up in 1 month
What do you want to do right
now?
• BP control
– Hydralazine 10mg IV x 1
• Pain control
– Morphine 5mg IV now
Reassess
• HR 40, BP 154/92
• Headache slightly improved but still there
Imaging
Imaging Results
• Non-contrast CT Head
– Normal
• CT Venogram
– Normal
More Blood Work
ALT normal
Bili normal
Mg2+ normal
Ca2+ normal
Alb 34
Uric Acid 410 (140-360)
LDH 336 (100-235)
Urinalysis – “I don’t have to pee”
She Finally Pees…
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Leuks Neg
Nitr Neg
Protein 1+
RBC’s 20/HPF
What to do
• Treat as pre-eclampsia !!
• Mg2+ IV
• Consult MTU
– They are puzzled by heart rate
– Consult Cardio & OB
– You go home and watch a ‘Who’s the Boss’ rerun
Late Post Partum Pre-eclampsia
• Does this actually exist?
--> YES
• Pre-eclampsia symptoms in a woman 48hrs to 4 weeks post-partum
• Overall incidence of pre-eclampsia is declining, but incidence of post
partum pre-eclampsia is rising (likely from early d/c out of hospital)
• Up to 25% of pre-eclampsia cases are post-partum
– 50% of these cases are beyond 48hrs
• 70% of these cases develop convulsions
• HEELP syndrome and more classic pre-eclampsia lab work is
appreciated only in a minority of late post partum pre-eclampsia, thus
have a lower threshold for treating these patients.
Late Post Partum Pre-eclampsia
Treatment
• Treat the same as you would regular pre-eclampsia, but you
don’t have a baby to deliver at the end
• Mg Sulfate 4g loading dose over 15minutes, then 2g/hr
infusion for 24-48 hrs while monitoring:
– Mg2+ levels
– reflexes
– urine output (Mg2+ is excreted by the KIDNEYS)
– Blood work 2-3x daily
Post-Partum Headache: Is Your Work-Up Complete?
– American Journal of Obstetrics and Gynecology - Volume 196, Issue 4 (April
2007)
Primary Headache
vs
Secondary Headache
•Dural Venous Thrombosis
•Post Puncture Headache
•SAH
•Post Partum Cerebral
Angiopathy
•Sheehan’s Syndrome
What about Post LP Headache?
• Post partum incidence roughly 2-22%
• 90% present within first 3 days of procedure, 66% within
first 2 days, but can develop up to 14 days after procedure
• An increase of the headache upon standing is the ‘sine qua
non’ symptom  Unless a headache with postural features
is present, the diagnosis of post-dural puncture headache
should be questioned. By definition, it “worsens within 15
min of standing, improves within 30min of lying down”.
• Diagnosis  is for the most part CLINICAL.
What About Dural Venous
Thrombosis?
Dural Venous Thrombosis
• Incidence in North America 10-20 cases per 100,000
deliveries, much higher in developing nations
• Most often occurs post-partum versus during pregnancy
• Mortality rate 4%
• Intracranial venous congestion and damage to vessel
endothelium secondary to mechanics of labour, in
combination with the increased hypercoagulability that
occurs postpartum
• Women remain ‘hypercoagulable’ 2 weeks post partum!
What’s the deal with the heart
block?
• Why did cardiology say it was ‘untypable’
2nd degree block?
Which Mobitz izit?
Mobitz I – block within the AV Node, progressive lengthening of
PR interval
Mobitz II – block below the AV Node, presumed to be healthy.
Most often, QRS is wide. A narrow QRS essentially excludes
infra-nodal heart block.
Our patient was a perfect 2:1 block with a narrow QRS… hard to
figure out!
*Only way to truly differentiate is intra-cardiac EPS. All Mobitz
Type II’s get a pacemaker, regardless of whether or not they are
asymptomatic.
How’s Our Patient Doing?
• BP controlled, oral long-acting Ca2+
blocker (Dihydropyridine!)
• Was on IV Mg 2+ infusion for 48hrs, had
2+ proteinuria next urine check, now zero
• Never had elevated liver enzymes
• No seizures
• U/S showed 5cm fibroid, no retained POC
• Cardiology will do EPS study
Any link between heart block and
labour?
• Case report following Ergot alkaloids
• Case report mom with Listeriosis during
pregnancy
• Congenital? A small percentage present late
in life
It could be worse…
Take Home Points
• Late Post Partum Pre-eclampsia can happen
up to 28 days after delivery
• Lower threshold to treat
• CT Venogram is the first choice to look for
dural thrombosis
• Lots of confounders, stick to the big things
you need to rule out given the context