On Saturday, I had one of those "holy ****......" moments.
I had a 47 year old female come in to the ED in full C-spine and backboard precautions after she had an apparent seizure at a bank. Apparently, the patient was doing her banking, started to stare, then had a 2-3 minute generalized seizure, all of which occurred in front of one of our neurologists, who happened to be behind her.
So, patient comes in, as above, and was post-ictal, with some somnolence and just feeling out of it. Was totally A+O in the ED, but didn't remember the seizure. Mild, nondescript HA, small abrasion to her scalp, nondescript neck tenderness. Nothing major on physical exam. Talking to her husband, she didn't have any pertinent medical history, no HTN, no CAD, no family history of seizure or stroke, or anything. Your run of the mill healthy 47 year old. Further questioning revealed that she had some sort of URI over the past week, with a cough and some runny nose, sore throat, etc.
Vitals were stable except for a temp of like 99.5 or something negligible like that. No HTN, no tachy, etc.
So, we did a CBC, CMP, tox, preg, ekg, etc, and go the head/c-spine CT.
CBC revealed a WBC of 17, with a slight left shift. CMP revealed a CO2 of 16, but no other major electrolyte abnormalities. EKG was unremarkable. CT's were unremarkable. Based on the history of URI and unknown source of seizure, went ahead and did an LP.
Lady's a small lady, like 120 lbs. Great landmarks. Get right in, no trouble. Pull out the stylette from the needle, and it comes out light pink and cloudy. I'm thinking it'll clear, maybe I hit a vessel or something on the way in. But, across 4 tubes, doesn't clear. Still light pink and cloudy. I called the lab and told em to spin the tubes after they get their counts, etc, and look for xanthochromia.
CSF comes back. Our CSF protocol does cell counts from tube 3, and glucose, etc from tube 1. 2 goes to culture and 4 is the spare.
Tube 3 count comes back with 14880 RBC's, and 0 WBC's. Spun down, still pink fluid. Protein was slightly high at 60. Glucose normal.
So, I start thinking...do I have one of those 5% of SAH's that are missed on CT? Call back to the lab and have em run cell counts on all the tubes.
Each tube had roughly 14000 RBC's and 0 WBC's, give or take a couple hundred RBC's. They never cleared between tube 1 and 4.
Called our neurosurgeon, who said to transfer to the quaternary care center down the road because our IR guys don't do coiling. So, we called quaternary mecca, and they accepted her for immediate angio. The quaternary neurosurgeon agreed that it was obviously SAH until proven otherwise.
So, yesterday, called down there to see what happened, and they said that they didn't see any aneurysms, but they thought that it was a traumatic SAH from falling down to the ground. They thought that when she had the fall, she may have disrupted some capillaries in the arachnoid space, which leaked the blood out into the CSF, but it had sealed itself off.
Goes to show you....you can't always rely on technology. And, LP really is the gold standard for SAH.
I had a 47 year old female come in to the ED in full C-spine and backboard precautions after she had an apparent seizure at a bank. Apparently, the patient was doing her banking, started to stare, then had a 2-3 minute generalized seizure, all of which occurred in front of one of our neurologists, who happened to be behind her.
So, patient comes in, as above, and was post-ictal, with some somnolence and just feeling out of it. Was totally A+O in the ED, but didn't remember the seizure. Mild, nondescript HA, small abrasion to her scalp, nondescript neck tenderness. Nothing major on physical exam. Talking to her husband, she didn't have any pertinent medical history, no HTN, no CAD, no family history of seizure or stroke, or anything. Your run of the mill healthy 47 year old. Further questioning revealed that she had some sort of URI over the past week, with a cough and some runny nose, sore throat, etc.
Vitals were stable except for a temp of like 99.5 or something negligible like that. No HTN, no tachy, etc.
So, we did a CBC, CMP, tox, preg, ekg, etc, and go the head/c-spine CT.
CBC revealed a WBC of 17, with a slight left shift. CMP revealed a CO2 of 16, but no other major electrolyte abnormalities. EKG was unremarkable. CT's were unremarkable. Based on the history of URI and unknown source of seizure, went ahead and did an LP.
Lady's a small lady, like 120 lbs. Great landmarks. Get right in, no trouble. Pull out the stylette from the needle, and it comes out light pink and cloudy. I'm thinking it'll clear, maybe I hit a vessel or something on the way in. But, across 4 tubes, doesn't clear. Still light pink and cloudy. I called the lab and told em to spin the tubes after they get their counts, etc, and look for xanthochromia.
CSF comes back. Our CSF protocol does cell counts from tube 3, and glucose, etc from tube 1. 2 goes to culture and 4 is the spare.
Tube 3 count comes back with 14880 RBC's, and 0 WBC's. Spun down, still pink fluid. Protein was slightly high at 60. Glucose normal.
So, I start thinking...do I have one of those 5% of SAH's that are missed on CT? Call back to the lab and have em run cell counts on all the tubes.
Each tube had roughly 14000 RBC's and 0 WBC's, give or take a couple hundred RBC's. They never cleared between tube 1 and 4.
Called our neurosurgeon, who said to transfer to the quaternary care center down the road because our IR guys don't do coiling. So, we called quaternary mecca, and they accepted her for immediate angio. The quaternary neurosurgeon agreed that it was obviously SAH until proven otherwise.
So, yesterday, called down there to see what happened, and they said that they didn't see any aneurysms, but they thought that it was a traumatic SAH from falling down to the ground. They thought that when she had the fall, she may have disrupted some capillaries in the arachnoid space, which leaked the blood out into the CSF, but it had sealed itself off.
Goes to show you....you can't always rely on technology. And, LP really is the gold standard for SAH.
