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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.

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Interesting Case Rounds

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  1. Interesting Case Rounds Mark Boyko EM Resident

  2. REDIS ‘Reason For Visit’ “Penis caught in the net”

  3. CASE • 30-year old middle-eastern woman presents to theER 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.

  4. CASE • VITALS: HR 34, regular BP 170/105 right arm RR 18 O2 96% on RA Temp 37.3

  5. 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”

  6. Past Med Hx • Born in Saudi Arabia • Denies any medical conditions • Denies previous heart problem • Mostly inactive • No medications • No drugs/EtOH

  7. 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”

  8. 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

  9. 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, verytender 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

  10. Thoughts So Far? About that heart rate…

  11. 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

  12. 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

  13. What do you want to do right now? • BP control • Hydralazine 10mg IV x 1 • Pain control • Morphine 5mg IV now

  14. Reassess • HR 40, BP 154/92 • Headache slightly improved but still there

  15. Imaging

  16. Imaging Results • Non-contrast CT Head • Normal • CT Venogram • Normal

  17. 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”

  18. She Finally Pees… • Leuks Neg • Nitr Neg • Protein 1+ • RBC’s 20/HPF

  19. 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’ re-run

  20. 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.

  21. 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

  22. 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

  23. 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  Unlessa headache with postural features is present, the diagnosisof 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.

  24. What About Dural Venous Thrombosis?

  25. 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!

  26. What’s the deal with the heart block? • Why did cardiology say it was ‘untypable’ 2nd degree block?

  27. 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.

  28. 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

  29. 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

  30. It could be worse…

  31. 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

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