Thoughts on this slightly baffling case?

[Guest ERCat]

I am a new grad, nine weeks into my first ER job. Today I had an interesting/confusing case and I would like your thoughts (as my supervising doctor and the hospitalist were baffled as well).

 

65 year old female with a history of CAD, MI four years previous (stents placed), and generalized anxiety disorder presented to the ER in the early morning with chest pain and nausea. Saw one of the other providers at this time. Her vitals/exam were normal. Labs including CBC, BMP, troponin I, chest x-ray were all normal at the time; EKG was NSR with PVCs. She was advised to stay for a repeat troponin I but left AMA. She bounced back to the ER in the evening via ambulance and became my patient. Apparently when she got home her daughter stated that all the sudden she began complaining of chest pain, then "suddenly slumped over, her eyes rolled back in her head, and she began twitching and shaking all over for a few minutes, with complete loss of consciousness" and the patient had no recollection of these events. The patient had no history of any seizure disorder so the daughter was obviously freaked out and called 911. When I saw the patient she was profoundly diaphoretic and nauseous, but chest pain free. She had mild epigastric discomfort she attributed to being hungry. She did not seem postictal, was alert and oriented and able to give a good history but had no recollection of the seizure like episode. She denied recent illness or trauma, no ingestions, no psych history except for anxiety, no history of seizures. No other symptoms like fevers, SOB, hemoptysis, edema, diarrhea, urinary symptoms, headache, dizziness, numbness, weakness, etc. Other than a bitten tongue and the serious diaphoresis her exam was normal - no rashes, heart and lungs sounded good, no edema or JVD, benign abdominal exam, non tender back, no calf tenderness or swelling and my entire rapid neuro exam was normal including normal coordination. We gave Zofran and Ativan. I ordered a bunch of labs on this patient - CBC, CMP, troponin I, Mg, phosphorus, TSH, urinalysis and urine drug screen. She did have an elevated white count, at 18K up from 12K from the morning. Elevated glucose at 200 (no history of diabetes) and 3+ glucose in the urine as well. Additionally a UTI according to the urinalysis. UDS Positive for marijuana only. Everything else normal. EKG unchanged from the morning, still NSR with PVCs but a little tachycardia. CT Head was negative. Then 2 hours after arrival she started complaining of chest pain AGAIN - my SP ordered aspirin and nitro which helped, and another EKG at this time (remained unchanged) and another trop... Which was elevated at 0.22. We admitted the patient for chest pain, elevated troponin, UTI and witnessed seizure like activity. Hospitalist was confused and asked me to ask the cardiologist what to do. Cardiologist advised us to five more aspirin and start a beta blocker, no heparin drip.

 

Anyone have any thoughts on this case? Things that should have been done differently?

 

Looking back I don't know why we didn't get a D-Dimer on this patient. Thoughts on this?

 

Also, can anyone think of a reason why my ER only orders troponin I for chest pain? I've never seen any other enzymes ordered even once in my time there...

[Guest ERCat]

PS Another random question. The nurse assigned to this patient took TWO AND A HALF HOURS to draw the initial labs even though she came in as AMS and chest pain. I was on the nurse multiple times and finally got charge involved and now the nurse hates me (LOL). I feel like in the future stuff like this could make me as a provider look bad - I don't think it's acceptable. When this stuff happens I would like to document in the chart there were issues with nursing but I've been told by other PAs that's a bad idea because it's throwing the nurse under the bus. Thoughts?

[Guest JMPA]

cxr? b/p?  angina? other drugs not tested for, the marijuanna is a flag, also consider aortic conditions/ pulmonary, pe is not a bad r/o

[Timon]

CKMB and myoglobin would be the other enzymes to order if you're thinking MI.

 

Did she have any carotid bruits? Seizure sounds like it could have been a TIA.

 

I don't think the D-Dimer would have done much in your management. If you're thinking PE at this point, do the CTA or VQ scan, but your pt is now admitted and in the right hands.

[jdenning]

Given the presentation the highest priority is getting the cards workup.   The neuro stuff is sort of interesting, but in a patient with generalized anxiety disorder (BTW what meds is this patient on for that?  Anything that might have QT interval issues?) I have a higher degree of suspicion that the "seizure" may have been a non epileptic event.  TIAs rarely present with twitching, shaking, eyes rolled back etc.  Neuro workup including EEG could be done inpatient if the resources are available or on outpatient basis

[tenjjetnis]

interesting case! I'm finishing up my er rotations right now and haven't seen other cardiac enzyme tests used either besides troponin.

 

This might be way off, I am still finishing up second year, but could this also be a hem/onc related issue, how was the pts platelets, pt/inr and kidney function the second time around ? The neurological changes can be related to clotting issues possibly exacerbated by tissue ischemia.

 

In terms of documenting the nurse in your note, in my opinion, I would never throw someone under the bus especially in a note , it could possibly come back to haunt you in the future. I was told by one of my preceptors to always be gracious to other colleagues when documenting.... but I am in an area where the healthcare community is fairly small.

 

Keep us updated with the case!

[db_pavnp]

If the troponin is negative, what will running a different cardiac marker do for you?

[EMEDPA]

didn't see if you did u/s of carotids but I would do that as well, also potentially more tox stuff if sz recurs. could have them do coronary ct and CTA at the same time for a bit more info.

[ventana]

Sounds more neuro to me for the second visit

Spin head is important to r/o bleed or mass

 

+ for MJ means she could have injested anything - and had a Sz

Biting tongue sounds like a real event neuro

 

BUT

 

Cardio is the one never ever miss, so I would say treat as a NSTEMI and admitt and let the hospitalist figure it out...

[GetMeOuttaThisMess]

FYI, VF may present initially as a sz. for those who have never seen it. Lost a roommate of a cousin from same at 28 y/o (IHSS known). This is "old school" thinking but non-transmural MI or micro vascular ischemia could account for CP and mild enzyme bump (used to see it post PCI, or PTCA). Thromboemboli not to be discounted either.

[Boatswain2PA]

Syncope can look like seizures.

 

Millions of causes of old people syncope, but most of them are cardiac.

 

Look at the San Fran Syncope Rule (CHESS).  

 

Top of my list

 

Paroxysmal V-tach

PE

MI

Dissection

TIA/Stroke

Brugada/WPW/Prolonged QT/etc

Vasovagal

 

She gets CTA chest, CT head, carotid sono, admitted to hospitalist, consult cards.  

 

Agree that CK/CKMB adds nothing to this.  I only draw them when I'm looking for rhabdo.

 

I would add prolactin.  That may help the downstream docs figure it out. 

[ventana]

Prolactin needs to be done ASAP after a seizure or of no value - like at the Sz is happening, drops back to normal quickly

 

As it was >2hrs for labs not sure it would be feasible...

[RuralER/Ortho]

Any update here ERCat?

[lightbearer06]

Seizure from an episode of hypoxia?

 

Could be an episode of VF like was mentioned.

 

Aortic dissection can cause chest pain with neuro issues.

 

It sounds like the troponin changed so ACS is the most likely etiology given the pt presentation...

 

Cast a wide net and then take what you are given. The only thing I could think to add would have been a CTA chest to ruleout aortic dissection depending on how the pt characterized the pain (sudden onset? radiating to back? etc)

 

Were there any risk factors for PE? Indiscriminate d Dimer usage is not generally helpful. Calculate your risk based on PERC score and Well's Criteria.

 

Troponin I is the most sensitive and specific cardiac enzyme. Both of the places I have worked have more or less told us to stop ordering CKMB. I have never even seen a myoglobin ordered. There were many patients when I worked in a chest pain center where the CKMB would be positive and the trop negative. The CKMB was generally ignored.

[rev ronin]

So I had a patient seize while being roomed last week.  I didn't see the seizure, but it was eyes rolled back and twitching as he was roomed.  Patient was 79 YOM with h/o getting off Warfarin 3 months ago for poorly controlled INR after years of trying to manage it.  So we sent him in, ER says "sounds like syncope", and after a detailed workup, finds a V/Q mismatch (he had an AKI), so they anticoagulated him again. Bizarre.

[sk732]

Maybe she was on a benzo for anxiety and switched to cannabis - Sz could have been W/D, as well as the other associated symptoms...just tossing that one out there.

 

SK

[winterallsummer]

Few things going on here:

 

1) pt p/w CP. May have been early angina or may have been due to anxiety, possibly triggered by aura which can precede seizure.

 

2) initial work up was unrevealing. Sounds reasonable and suspect repeat troponin would've been negative. Only thing that could've been missed is if the CP was accompanied by something else and maybe was an aura. Could've tried to admit the pt as obs but is a moot point since they left AMA.

 

3) pt seized at home. No obvious secondary cause here. While older patients are more likely to have a secondary cause (eg brain mass), many also have epilepsy disorder just diagnosed late in life. Agree with Ativan and starting AED or could've keppra loaded and continued keppra on floor. Needs EEG done on floor and appropriate work up for second cause which may or may not include MRI brain depending on suspicion, although CTH was negative. Also the pt sounds squirrelly. Maybe they took a drug that doesn't show on UDS such as K2. Besides starting Ativan or keppra that is basically the hospitalists job to further eval.

 

As others mentioned syncope can occasionally be confused for seizure. So if the pt had syncope then a CTA of chest to rule out dissection or less likely PE would be reasonable. That may be a little by overkill if the pt had no other supportive symptoms. Usually (but not always) dissection reveals itself in extremis. Anyway d dimer is not sensitive and probably would've been positive regardless. If the CP was convincing I don't think it would be wrong to rule out dissection. But if clinical suspicion was low I wouldn't fault you for not going down that road. That being said sounds more like sz than syncope.

 

4) Leukocytosis and hyperglycemia were probably stress reactions from the seizure (like you see in traumas). Unless the pt had dysuria , even with a "positive UA", sort of doubt this was an actual UTI.

 

5) intermediate trop and clean EKG. Needs another trop in a couple hours. May be related to other cardiac issue (see above) if flat. Or could have an NSTEMI cooking from all the stress from a seizure.

 

I don't think you missed anything. If the pt worsened, it might be worth getting CTA chest. D dimer will probably be positive no matter what in this case and not helpful. Otherwise needs serial troponins, tele, EEG and AEDs and see what the labs show tomorrow. Not necessarily wrong to tx UTI if you can't tell what the hell is going on and DC if culture returns negative. But also reasonable to defer that to hospitalist.

Just make sure you got urine cultures.

 

The one thing that explains both seizure and CP w trop elevation is drug use missed by UDS. That would have to come from pt hx.

[winterallsummer]

ALso troponin I is best enzyme for MI. Others are too non specific. They can rarely be helpful if negative. Anyway I usually only use troponin if looking for MI or other cardiac damage.

 

Remember demand ischemia, PE (typically w right heart strain) or other insult to the heart also raise trops. I used to get excited about intermediate trop but unless there's a good story these often remain flat. Can always repeat in a couple hours rather than waiting four to six if you think it's the real deal. And repeat the EKG alongside it. Then begin appropriate tx accordingly.

 

Remember that history is king so if you thought it was ACS with intermediate trop then you can consider starting AC. However I think you made a very safe bet by deferring that to cardiology. Or can always wait and check the trop in a little bit. If it's ACS that trop is going to go up.

[Moonchi]

Neuro symptoms + CP makes me think of dissection. I would have scanned her chest. Also endocarditis as patients can get septic emboli to the brain.

 

 

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[SERENITY NOW]

I agree with what some of the above have already said... seizure-like myoclonic jerks (sometimes even true seizures) often occur as a result of syncope, a phenomenon called "convulsive syncope".  In a patient with known significant CAD, no seizure hx, with recent onset of anginal sx and then a presentation of "seizures" with a very brief postictal period, the primary issue is most likely cardiogenic syncope.  As such, top priority is cardiac workup and tx, then neuro after the fact (or in parallel).  

 

 

Check this out for a pretty good synopsis:

 

http://www.pemcincinnati.com/blog/synconvulsions-just-common-convulsions-syncope/