Clinical Case 146: Heady Heart
Welcome back to the first Clinical Case for 2019. I have been having a great break over the summer doing a bit of travel and spending a lot of time in the ocean. For a look at my latest photographic adventures check out the pics here
The case today starts in a small community clinic several hours drive away. This one is an exercise in risk and uncertainty.
A 55 yo man was driving between a few remote communities in an un-air-conditioned car in January (in the Kimberley that means 100 F and 100% humidity) for half a day. He began to feel unwell about 50 km from the clinic and stopped on the side of the road as he felt like he was going to pass out. He developed a headache which came on over a few minutes and peaked within 10. The headache was initially quite severe but faded over another 10 minutes to be more of a “dull ache”
When he stood beside his car he felt “weird” and had subjective weakness in his right arm and was unable to speak properly. He tried to use his mobile phone to call for help but was unable to make any words. Being a stoic Aussie bloke he decided to get back into the car and drive into town. The weakness and speech disturbance resolved in the 30 minutes he took to drive to the clinic.
On arrival to the clinic the remote-area nurse has done observations and placed an IV. His BP is 160/80, pulse regular at 75, other all in normal range. BSL 6.6 mmol/l. She could not detect any clinical weakness, facial droop or dysphasia. But….
… as you were discussing the plan our man started complaining of anterior chest pain. The pain was abrupt in onset and radiated up from his chest to his neck. You ask for an ECG and a call back!
The ECG is normal. The clinic does not have any ability to do POC troponin. The pain did settle with a single dose of SL GTN.
FIRST QUESTIONS:
- What do you think is going on?
- Would you prescribe anti-platelet or anti-coagulation at this stage? If so, what?
The Royal Flying Doctors are alerted and they estimate that they can retrieve this chap within an hour or two.
… 3 hours later. Our patient has arrived in your rural hospital and has a mild headache. The chest pain has not returned and several more ECGs have been normal. He is neurologically normal to examine. A fresh blood sample is collected… the troponin is mildly elevated at 0.12 [ <0.04 ng ]
SECOND QUESTIONS:
- What tests would you like to do and in which order?
- Will you change your anti-coagulation plan at this stage?
- What do you think is going on now?
A CT of the brain is performed and this is reported as normal approximately 7 hours after the initial headache symptoms. An LP is subsequently performed around the 12 hour mark and this was essentially clear – with 2, 1 and ZERO red cells in the 3 tubes… xanthochromia will be unavailable for at least 24 hours.
THIRD QUESTIONS
- Where to from here?
- Does he require any more investigation? Your small hospital cannot perform advance angiography or MRIs!
- What is the disposition plan?
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About The Author
Casey Parker
I am a GP working in Broome, NW of Western Australia. I work as a hospital DMO (District Med Officer) doing Emergency, Anaesthestics, some Obstetrics and a lot of miscellaneous primary care. Also on the web as @broomedocs | + Casey Parker | Contact
So, this man has had a transient neurological event of some sort. Must presume that this is vascular, although migraine or central neurological causes also possible.
Normal CT reassuring but doesn’t help the diagnosis really.
I’m thinking dissection needs to be excluded. Chest pain radiating to the back is a classical (albeit uncommon) sign of aortic dissection which could extend to carotids. Would prefer not to anticoagulate this!
Alternatively could be a vertebral dissection (chest pain a red herring?), which would benefit from LMWH for example.
An echo might rule in the former if there was anyone handy with a probe…?!
Not sure how good US would be for the vertebral arteries though!
I think he needs angiography and would holdnoff anticoagulation for now.
Nice easy one to get us started Casey!? Complex case indeed. I wouldn’t anticoagulate until the CT cleared a haemorrhagic stroke. He’d need clexane post Troponin result for sure. Cerrebellar infarcts don’t show well on a CT so I’m still going with TIA and would be closely monitoring him and arranging MR or CT with angiography carotid Doppler’s and echo. I’d like to know more about his PMHx and cardiac risk factors. I would remain highly suspicious about his ongoing IHD risk and would be arranging subacute coronary angiography.
Mmmm
?premorbid issues
What medications is he on? Is a beta blocker masking what should be a tachycardia
5% dehydration can cause headache
And those roads this time of year are jolly hot
How much water has he drunk? Electrotechnical replacement or just plain water?
How much frog did he drink last night ?
? Acute pre renal renal failure with electrolyte disturbance – disequilibrium syndrome/
Sodium disruption…. causing neuro symptoms
Chest pain secondary to arrhythmia or uraemia or both
UEC’s – ??
Fluids
Mg
Potassium lowering regimes if potassium up
Clexane
Monitored bed
HDU
Trop is elevated in ARF
I would still have done the CT
??
This sounds awfully familiar.
My initial concern was/is regarding aortic/vertebral dissection given the symptoms at and above the chest.
other ddx’s: MI +/- TIA, SAH
1. I’d like a CT angio – arch of aorta to CoW
2. I wouldn’t anticoagulate until negative LP xanthochromia with the relative clinical concern for SAH. Also how much is there to gain from therapeutic clexane?
Casey you must have the data for this somewhere.
I think from the information provided it sounds like he’s had an MI. If he has had a cerebral bleed it is probably a small one (given normal CT at 7 hours) therefore I think the relative benefits/risks of giving aspirin are leaning towards giving.
3. Disposition. Tertiary hospital for MRI and angio ? PCI.
Yes. The potential risk of heparin vs. gains if he is having a non-STEMI are very low
Justin Morgenstern just posted a fantastic review of the data here: https://first10em.com/heparin/
We do like to “do something” in these tricky cases. Discussion with super specialists often leads to doing more stuff… which may not be the right thing!
Agree. No anticoagulant until bleed excluded… which effectively is close to impossible without a 24 hour wait
C
I was going to pipe in with that, but glad you beat me to it. Heparin doesn’t save lives, so definitely shouldn’t be used in questionable cases.
Chest pain plus neurological symptoms is getting a dissection work up from me, although I will note that after making a big deal about how hot it is, you never gave us a core temp as part of his vitals.
I’m with Cherelle ?episode of heatstroke causing AKI and subsequent spurious rise in troponin be high on my differential list given history VBG UEC and CK would be useful. Wouldn’t rule out IHD or dissection without further info but even stoical country blokes can get a bit anxious when attending bush clinics and hyperventilate a bit! Looking forward to hearing how case unfolded
Hi Broomers,
First time posting on this site. I work in remote part of Canada (Haida Gwaii if you want to go on a Google Maps adventure) so feel for the outback Aussies. Thoughts on the case:
1. Not SAH
2. Ddx:
-Heat stroke – temp was suspiciously left out and the first sentence is very suspicious.
-Dissection – measure BP in both arms, and look very hard for a flap on POCUS (parasternal long and the suprasternal views). I would try to do doppler flows in each carotid too, looking at carotid VTI. If there is a difference, points to differential flow, maybe from dissection. Also, you can look for gross atherosclerosis of the common. Depending on habitus, can see into the IC too.
Welcome Tracy
Awesome ideas with POCUS
Hard to exclude dissecting bedside but if you see something bad… the disposition becomes urgent
Love it
I’m way across the pond in the US, but love the idea of the Royal Flying Physicians! I’m applying the Chest Pain + 1 rue here, and in his case, Chest Pain + 2. That is chest pain plus one other finding (extremity weakness, neuro symptoms, etc.) I’d say he is a dissection until proven otherwise. I would start by reducing his BP with Esmolol while awaiting CTA of the neck and Chest (or in my center down to the toes just in case that’s where he is dissecting from). If bedisde Echo is available that may be helpful if a flap is visualized. I wouldn’t do much more than that until we have the CT results. (First time poster)
Thanks Stephen
Good thoughts
Unfortunately esmolol is not a drug we carry in small hospitals or retrieval service (even Royal ones)
C