Interesting case rounds
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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

Interesting Case Rounds

Mark Boyko

EM Resident


Redis reason for visit

REDIS ‘Reason For Visit’

“Penis caught in the net”


Interesting case rounds

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.


Interesting case rounds

CASE

  • VITALS:

    HR 34, regular

    BP 170/105 right arm

    RR 18

    O2 96% on RA

    Temp 37.3


Interesting case rounds

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

Past Med Hx

  • Born in Saudi Arabia

  • Denies any medical conditions

  • Denies previous heart problem

  • Mostly inactive

  • No medications

  • No drugs/EtOH


Pregnancy hx

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”


Interesting case rounds

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

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


Thoughts so far

Thoughts So Far?

About that heart rate…


Blood work

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

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

What do you want to do right now?

  • BP control

    • Hydralazine 10mg IV x 1

  • Pain control

    • Morphine 5mg IV now


Reassess

Reassess

  • HR 40, BP 154/92

  • Headache slightly improved but still there


Imaging

Imaging


Imaging results

Imaging Results

  • Non-contrast CT Head

    • Normal

  • CT Venogram

    • Normal


More blood work

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

She Finally Pees…

  • Leuks Neg

  • Nitr Neg

  • Protein 1+

  • RBC’s 20/HPF


What to do

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


Late post partum pre eclampsia

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

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


Interesting case rounds

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

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.


What about dural venous thrombosis

What About Dural Venous Thrombosis?


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

What’s the deal with the heart block?

  • Why did cardiology say it was ‘untypable’ 2nd degree block?


Which mobitz izit

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

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

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

It could be worse…


Take home points

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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