VIP Case treatment... why you shouldn't do it

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.

roja

Full Member
7+ Year Member
15+ Year Member
Joined
Oct 20, 2003
Messages
6,040
Reaction score
23
I have a brief moment or two so I thought I'd throw out an amazing (I thought) case that I had a few weekends ago, working the overnight....


70ish male, retired MD, visiting from out of state. Was at the opera and during intermission developed sudden onset of unilateral leg paralysis. Was diaphoretic and didn't feel good. No CP, SOB, n/v. (15min PTA). Hx of very mild HTN, controlled with HCTZ. According to him and spouse pressure was never more than 130/80's at home. Has mild parkinsons.

On exam, patient mildly distressed, asking for tpa. VSS (nl bp, not tachycardic, pulse ox 100%). Exam significant only for complete paralysis of unilateral LE. Pulses intact, warm, perfused. EKG nl (not even flipped twaves, etc). Pt is rushed to head CT. In the meantime, labs sent.

When patient comes down, he has full recovery of his LE but is in excrutiating pain (8mg MSO4x2, 2mg Dilaudid got it under control). He is still wanting tpa. Exam is now completely normal, with no reason for the pain. Quick ultrasound of abdomen shows a normal aorta. Labs have come back and are nl except for a lactate of 6.5. BP in both arms are equal.

What do you want to do?:)

Members don't see this ad.
 
Does he meet the criteria for Tpa? Of course not

Who he is and what he wants is totally irrelavent.

I can just hear his attorney now:

Doctor, please give me some justifacation for giving the Tpa that lead to his massive ICH.
 
I have a brief moment or two so I thought I'd throw out an amazing (I thought) case that I had a few weekends ago, working the overnight....


70ish male, retired MD, visiting from out of state. Was at the opera and during intermission developed sudden onset of unilateral leg paralysis. Was diaphoretic and didn't feel good. No CP, SOB, n/v. (15min PTA). Hx of very mild HTN, controlled with HCTZ. According to him and spouse pressure was never more than 130/80's at home. Has mild parkinsons.

On exam, patient mildly distressed, asking for tpa. VSS (nl bp, not tachycardic, pulse ox 100%). Exam significant only for complete paralysis of unilateral LE. Pulses intact, warm, perfused. EKG nl (not even flipped twaves, etc). Pt is rushed to head CT. In the meantime, labs sent.

When patient comes down, he has full recovery of his LE but is in excrutiating pain (8mg MSO4x2, 2mg Dilaudid got it under control). He is still wanting tpa. Exam is now completely normal, with no reason for the pain. Quick ultrasound of abdomen shows a normal aorta. Labs have come back and are nl except for a lactate of 6.5. BP in both arms are equal.

What do you want to do?:)

great case.

what were his reflexes and sensory exam like on the affected extremity initially? any back pain or spine tenderness? any history of transient focal neurodeficits including transient vision loss?
 
Members don't see this ad :)
Initially, he had sensation intact and 0/5 strenght in the LE (all the way the way up including quads and hamstrings). No back pain or spinal tenderness. No transient deficits (other than the leg) or vision loss.

And agreed FISKUS but VIP treatment is a known entity.. and its a catchy way to get people in to see the thread. ;)
 
Don't do it. And inform him of the nice >$1100 price tag.

The question isn't to give him tpa or not. (it wasn't) but what do you want to do NOW. :)
 
What did the CT head show? I'm assuming it was negative. Sounds like the key is with the elevated lactate level. - Any other lab values. Elevated CK or perhaps urine dip w/ urinalysis. You may have normal large vessel pulses but still have microvessel ischemia of the leg. ?compartment syndrome w/ nerve compression. Maye he sat in his chair at the opera too long. Consideration stat CT abd/pelvis.
 
What did the CT head show? I'm assuming it was negative. Sounds like the key is with the elevated lactate level.

Head CT showed no acute ischemia or bleed.


What now?:confused: :confused: :confused:
 
CT abd/MRI lower back. Sounds like a disk problem to me.
 
Any swelling in the affected leg? How about rectal tone? Any other neurological findings at all? Any history or family history of similar episodes? Prodromal illness? Recent travel? Any other lab abnormalities (a la hypo/hyperkalemic periodic paralysis, etc.)?

I agree, sounds like a nerve root problem / radiculopathy (given the pain) versus vascular in etiology (especially worrisome for arterial thrombosis, hemorrhage, etc.) vs. compartment syndrome vs. Guillain-Barre vs. ALS (except for the pain) vs. MS vs. ?. Can you have Saturday Night Palsy of the leg?

I would probably check a CK and MRI his neuraxis. I would also consider US or otherwise imaging the affected leg to check for hemorrhage into the thigh, ? check compartment pressure, Ankle-Brachial index, possibly an arteriogram or equivalent of the leg. Not sure what to make of the elevated lactate, but it's certainly concerning that something may be dying somewhere (or he just ran a marathon). If I really thought it was embolic, an Echo may be warranted.

I don't know, but I"ll be interested to hear "the rest of the story". Maybe he just really didn't like that particular opera and decided he'd rather spend the night in the ED. I certainly wouldn't give him tPA.
 
Don't do it. And inform him of the nice >$1100 price tag.

On a side note.. i doubt a retired MD is worried about 1K if he is really having a stroke.. he can afford it.. now does he need it or should he get it? HELL NO. but cost isnt the issue.
 
I would probably check a CK and MRI his neuraxis. I would also consider US or otherwise imaging the affected leg to check for hemorrhage into the thigh, ? check compartment pressure, Ankle-Brachial index, possibly an arteriogram or equivalent of the leg. Not sure what to make of the elevated lactate, but it's certainly concerning that something may be dying somewhere (or he just ran a marathon). If I really thought it was thrombotic, an Echo may be warranted.

Why not just admit him to neurology and let them do this on the floor...
 
The pain -- is it localized to the LE as well? Can he pinpoint it, or at least tell you distal vs proximal, anterior vs. posterior, etc.?

An exhaustive 19th-century style neuro exam might be in order. Get the pain reduced to a level of tolerability, then make him walk on his heels and on his toes; test reflexes everywhere he has them... find the nerve root responsible. A disc problem is on the list...

Then again, wait until the ultrasound. What about a freaky DVT-style issue, or an infarction of some muscle bundle way deep? Has this guy seen any episodes of House?
 
Members don't see this ad :)
This sounds nothing to me like a neurological problem. The elevated lactate is pointing to an arterial problem (disc disease does not produce tissue ischemia)........I would be concerned for vascular etiologies---dissection/aneurysm/pseudoaneruysm/embolic/thrombotic disease and pursue the appropriate studies.
 
did you get a sed rate?
 
On the venous side as well (though this case doesn't sound like it) there are always large pelvic dvt's causing phlegmasia alba dolens---->phlegmasia cerulea dolens.


 
This sounds nothing to me like a neurological problem. The elevated lactate is pointing to an arterial problem (disc disease does not produce tissue ischemia)........I would be concerned for vascular etiologies---dissection/aneurysm/pseudoaneruysm/embolic/thrombotic disease and pursue the appropriate studies.

I agree. Known HTN, sudden onset symptoms. In my short experience as an EM resident (n=4 years), I have seen dissection present atypically more often than not. Additionally, I am not sure about whether I alone would treat a cva with such limited symptoms with TPA ( and turn relative minor symptoms to ICH....My lawyer isn't that good).
If he's got pulses in the lower extremity then thromboembolism (at least an acute occlusion) becomes less likely.
 
I'm sorry, but when Roja posts a case like this, I think zebras, not horses. Perhaps I'm wrong and it's a simple clot in the femoral artery or somewhere along the leg.

I agree with others that neurologic causes should not cause a lactic acidemia. One must also ask if this is a real lactic acid result. What was the tourniquet time? If it's greater than two minutes (i.e., the patient was a difficult cannulation for IV access), then there can be a falsely elevated lactic acid level.

However, if we say the patient was an easy cannulation and the tourniquet was not on for a prolonged period of time, then this likely points to some sort of ischemia. I do not know of any data to suggest that neurologic infarcts (i.e., brain or spine) will generate lactic acid.

A better question might be why was the lactic acid sent? Were you thinking of ischemia, sepsis, or another reason? I have never ordered a lactic acid on a suspected stroke patient.

What is the ABI? Was a CT done with a dissection protocol (ultrasound is often normal in acute dissection, although this is rarely isolated to the abdomen alone)?

What was the complete neuro exam like?

Could there be a spinal infarction, possibly from an aortic dissection or even a clot/dissection in one of the spinal arteries? The artery of Adamkiewicz springs to mind (thanks to a general surgeon during medical school who loved to quiz medical students on it). Could there be a clot or dissection here? I think it enters on the left of the spine and supplies the lower thoracic/upper lumbar area, which could explain his findings.

I'm interested to see what develops of this thread. :)
 
Why not just admit him to neurology and let them do this on the floor...

a.) I'm not entirely sure I would trust the Neuro team at my facility, especially if given a non-neuro case
b.) I'm still not sure the etiology is neurologic at this point (seems more likely not)
c.) Based on the results of further testing, I would probably end up calling Vascular or Neurosurg directly

Is that reasonable? Or too much? Please correct me if I'm wrong - I value your input!

Given the title of the thread ("...why you shouldn't do it"), I'm going to venture a guess that this guy has some bleeding somewhere, got tPA (because he's a doc and asked for it) and something bad happened...
 
Wooohooo. Great points.


So to clarify a few questions: the tourniquet time wasnormal.. easy access. The lactate was sent by accident, because when the nurse drew blood she drew all tubes and it was a day where the lab wasn't demanding slips so even though it wasn't ordered, they ran it.

We are a designated stroke center so the stroke team was called for the possible CVA (at this point no CT, and a paralyzed leg). The stroke attending and I agreed that no tpa was warranted based on the size of the defect and the pts stroke scale. By the time the stroke attending saw him (about 45 min) he got a full nuero eval, which showed nothing.

The dorsalis pulse in the affected leg was slightly diminished now but was still warm, well perfused. the pain was affecting his entire leg. Pt's BP was never more than 120/85. Surgery wanted to give heparin and admit for embolic work up.

I was still uncertain as nothing was playing out well, so I wanted to scan his belly to look for aortic dissection and we ended up scanning his neck, chest and abd/pelv.

He had a dissection from the root of the aorta all the way down into the renals and iliacs. He also had dissected up into the right carotid to the bifurcation.

Needless to say, he didn't get tpa, or heparin but was taken straight to the OR that morning.

36 hours later, I saw him sitting up in a chair, watching tv and raring to go.


So yeah... aortic dissections can be wonky.... Strong work with the differentials! I'd try and get images but I don't think SDN can handle them.
 
So weird, He's dissecting his ENTIRE aorta and the place he gets the pain is his LEFT LEG!
 
Wow! Great case! Just out of curiosity, did the CXR show any of the classic findings? Or maybe did it seem so after the retrospectoscope was in place?!!

Good job with this one!
 
Wow! Great case! Just out of curiosity, did the CXR show any of the classic findings? Or maybe did it seem so after the retrospectoscope was in place?!!

Good job with this one!



Not even in retrospect. Cold stone normal.
 
(just an M1, so be gentle).

Why was the ultrasound of the abdominal aorta negative if the dissection went all the way from the root of the aorta to the iliacs?
 
Abdominal ultrasound is relatively insensitive for dissection.
 
Wooohooo. Great points.


So to clarify a few questions: the tourniquet time wasnormal.. easy access. The lactate was sent by accident, because when the nurse drew blood she drew all tubes and it was a day where the lab wasn't demanding slips so even though it wasn't ordered, they ran it.

We are a designated stroke center so the stroke team was called for the possible CVA (at this point no CT, and a paralyzed leg). The stroke attending and I agreed that no tpa was warranted based on the size of the defect and the pts stroke scale. By the time the stroke attending saw him (about 45 min) he got a full nuero eval, which showed nothing.

The dorsalis pulse in the affected leg was slightly diminished now but was still warm, well perfused. the pain was affecting his entire leg. Pt's BP was never more than 120/85. Surgery wanted to give heparin and admit for embolic work up.

I was still uncertain as nothing was playing out well, so I wanted to scan his belly to look for aortic dissection and we ended up scanning his neck, chest and abd/pelv.

He had a dissection from the root of the aorta all the way down into the renals and iliacs. He also had dissected up into the right carotid to the bifurcation.

Needless to say, he didn't get tpa, or heparin but was taken straight to the OR that morning.

36 hours later, I saw him sitting up in a chair, watching tv and raring to go.


So yeah... aortic dissections can be wonky.... Strong work with the differentials! I'd try and get images but I don't think SDN can handle them.


Great case!!!:thumbup:
 
I bet he is glad he didn't recieve his demanded TPA! :D
 
Wow, a dissection like that doesn't happen overnight. Amazing he didn't have ANY symptoms at all until intermission at the opera, and even then, only had left leg symptoms.
 
Why not just admit him to neurology and let them do this on the floor...

Isn't this why EP's get a bad reputation? I think it's good practice to have a little more of an idea of what's going on...
 
:eek: OK, I'm scared.
 
Its not necessaryto be scared. Aside from being an interesting case (and a wicked cool CT), one of the key points is to rememer to keep your differential diagnosis open. (I didn't pick this one up because I thought, hey, I bet this guy has a dissection.... but because I couldn't quite piece everything together and nothing was making complete sense to me... dissection had been in my differential but low... )

For the M1- abdominal u/s is good for picking up AAA, which can also dissect, but pure dissections are not easily picked up by u/s.

It is amazing that he had never had any syptoms.. nothing... no chest pain, etc.
 
Wow, great case. Definitely tightens the sphincter. It just goes to show you that when something doesn't make sense, don't shrug it off, look harder.
 
Even stranger than this being a cool case is that I JUST HAD THE SAME CASE at my hospital a month ago!!!

39y/o dissected brachicephalics/both carotids/arch/thoracic/abdominal/both iliacs. Only history was HTN.

chief complaint of severe tearing, sudden onset of chest/back pain radiating down to belly.

Also had right leg numbness/tingling/with diminished pulses.

ended up dying, but what are the chances that both roja and I have the same case with leg involvement within 1 month!?

cool.
 
My boss was telling me about his case of dissection where the patient (35 yo F otherwise healthy) came in screaming that her siatica was hurting and she needed pain meds. That patient had dissected all the way up and ended up dying. He told me about the case and just happened to pick up the lawsuit notice later on that same day.

Aortic dissection must be ruled out in this case. Anything with abd/chest pain (doesn't mention pain location in original case) and neurological deficits is a dissection until proven otherwise.
 
I've always heard it "stone cold normal" - do you have ice cream on the mind?

Quite possibly.. my mind does tend to have several things running at all tmes.. until it collapses. ;)
 
39y/o dissected brachicephalics/both carotids/arch/thoracic/abdominal/both iliacs. Only history was HTN.
Vascular EDS? Marfan's?
 
Abdominal ultrasound is relatively insensitive for dissection.
This warrants repeating, in bold letters:

Abdominal ultrasound is relatively insensitive for dissection.

It's great at picking up abdominal aneurysms, but not dissections (which are NOT aneurysms). Dissections are tears in the wall of the aorta. Sometimes you can see a flap on ultrasound, but usually ultrasounds are normal (except for TEE's).

Aortic aneuryms usually burst, not dissect. Our vascular surgeons tell us that dissections rarely happen in aneurysms. The aneurysm can leak or completely rupture.
 
Awesome case Roja!!! Excellent outcome too. :thumbup: :thumbup:




I was very happy for him and his family. Its nice when it all works out wel.


*wipes sweat from brow*:D
 
I was very happy for him and his family. Its nice when it all works out wel.


*wipes sweat from brow*:D


My most unusual dissection was a guy that had painless hematuria. The anal PCP was of course thinking bladder ca, could not get a cystoscopy done, and did an abd CT. The radiologist noted the dissection and continued the CT of the chest. He had dissected from stem to stern. No other symptoms. Went to the OR.

mike
 
Top