78 year old female CC: Headache

Here’s a case submitted by a faithful reader by the name of Nick Mercer.

EMS is dispatched to “possible heart attack” in rural Montana.

On arrival they find a 78 year old female lying on the couch where her friends found her in the morning.

The patient is awake and oriented but not alert. Speech is clear and appropriate but sluggish. She states that she has been lying on the couch for less than 1 hour.

The paramedics determine that she is complaining of a headache.

From bystanders they learn the patient as a past medical history of CVA, CHF, and MI.

The patient is cool, pale and diaphoretic.

During a neuro exam paramedics discover right-sided facial palsy and left-sided arm drift.

The patient starts to vomit.

Because they are 50 minutes from the hospital, the paramedics call for aeromedical transport.

The patient’s head appears to be atraumatic. She denies recent falls. She denies chest pain or shortness of breath.

Vital signs are assessed.

RR: 24
Pulse: 90
BP: 216/134
SpO2: 98 on oxygen via NRB @ 15 LPM

BGL: 168

A 12-lead ECG is captured.

The patient is more lethargic by the time aeromedical transport arrives although the other neurological symptoms have resolved. She still looks acutely ill.

The patient has vomited a total of six times but stops after being treated with IV Zofran.

Repeat vital signs are assessed.

RR: 20
Pulse: 88
BP: 164/110
SpO2: 99 on oxygen via NRB @ 15 LPM

An additional 12-lead ECG is captured.

What is your impression of this patient?

29 Comments

  • jake says:

    sounds like either S/S of a stroke or hypertension cause by her medical history

  • Karen says:

    The EKG needs to be compared to an old one. I wouldn’t think this would be the problem though. My worry would be the HTN and MAP of 161, HA with vomiting. Without at CT my guess would be a bleed.

  • D W says:

    Impression == Stroke. Second IV with labs, continue O2, fsbs to rule out hypoglycemia, R/O SZ, medication OD (bystander history probably only option), toxins. Prepare for intubation if pt. mental status continues to deteriorate. After the second BP, pt. no longer is in hypertensive crisis, but air evac probably still indicated.

  • Caroline says:

    I agree with Jake. That was my first though based of symptoms and history.

  • Jim says:

    I agree with Karen that it is probably a bleed. The elevated pressure and vomiting along with neurological symptoms seems to fit the bill. The inverted T waves in the first 12 lead are probably ischemia caused by the elevated pressure. Initially I thought they might have just been old ischemia from the prior MI but the fact that they are resolved in the second 12 lead and the significant drop in pressure tells me it is probably a brain issue as the body is compensating to maintain the oxygen delivery to the brain rather than a cardiac issue. Lethargic is a pretty general term too, I’d want to know a little more specifics on the neuro assessment. Did she have a gaze?

  • Matthew says:

    What is her SpO2 on room air? 15lpm seems like overkill if she’s not otherwise hypoxic. (yes, our medical director subscribes to the theories on free radicals and over-oxygenation)

  • Abby says:

    I agree with Karen. From the S/S it looks like a hemorrhagic stroke. For the neuro exam, it seems to general and I can’t really tell what it is. But I have to say air transpo was a good idea.

  • Brandon O says:

    Spontaneous bleed. ECG changes are just neurogenic stunning.

  • Matthew says:

    I agree with karen, id need to see and old 12lead to compare. But the depression seems to be resolved in the second ekg. The 15lpm could be turned down a bit, no need to over do it..

  • tim hicks says:

    she sean to have a blead i would think more on the line of a stroke

  • Christopher says:

    I’m concerned for SAH given S/S, potentially ischemic stroke, but my largest concern is a CVA.

  • Meriah says:

    My field diagnosis would be cva, probable bleed. I would treat with rapid transport (air for a 50 min transport) high flow 02 probably 12 to 15 lpm via nrb if tolerated regardless of spo2 level, bilateral int’s, iv zofran for vomiting. Cardiac monitoring, and 12 lead ekg..I couldn’t read what the example showed, however I would treat for cva. I would also question if the patient had truley only been feeling this way for one hour, when did someone last see, Her normal or speak with her, is it possible she has been there much longer??? If so air evac may not be neccesary if the time window has passed.

  • kristina says:

    TIA maybe hx of CVA.. its a possibility… sudden onset… gone as fast as it came.. maybe… anyone know what it was for sure…

  • M says:

    Prolonged QT interval can indicate SAH (QTI>0.5RR)
    Given her other related symptoms, it seems likely a neuro diagnosis

  • M says:

    hypertensive crisis?

  • Dave B says:

    it is possible for an MI to present as stroke… in the first ECG, there appear to be inverted p waves in lead II, and there is also a bigeminy of PVC’s… the inverted T waves are appropriately discordant for these complexes. in the non-pvc complexes, there appears to be subtle st depressions in I and aVL.. considering the small voltage in aVL, the depression could be significant. it is possible that these could be reciprocal to inferior st elevations that are not visible yet. also, there appears to be st depressions in the lateral leads V5 and V6. in the anterior septal leads, QS complexes could be due to old MI, but, there appears to be ST elevations in V1-V3, which seem to change in the second ECG.
    in the second ECG, the bigeminy of PVC’s has resolved, and the P waves in II are now upright. the ST elevations in V1-V3 seem to have diminished somewhat, with QS remaining in V1 and V2..still subtle depressions in V6 and aVL..
    while S/S of something possibly neurologic, there are dynamic ECG changes happening on these 12 leads, which are concerning.

  • Will says:

    Here is my take. This is a difficult case to assess. You have 2 variables that puts EMS providers in a difficult situation, and have to treat based on presentation, and having a high index of suspicion for the worst case scenarios which in this case there are two, MI and CVA and CC of a headache determined by the paramedic onscene. So I’m going to give my take by breaking everything down step by step which is how I tend to think.

    Starting with the basic vital signs.
    RR: 24 Assuming Normal Tidal Volume This is is slightly high. Could be related to CHF (orthopnea) upon initial presentation.

    Pulse: 90 Fairly normal

    BP: 216/134 Ominous Hypertensive Crisis. With a MAP of 161 mmHg may suggest hypertensive encephalopathy. Red Flag

    SpO2: 98 on oxygen via NRB @ 15 LPM- What was the baseline prior to placing the patient on oxygen.

    BGL: 168 Slightly elevated not necessarily concerning at this point.

    12-lead analysis.
    You see a possible ectopic atrial rhythm ( need a longer strip to further diagnose WAP but not really important I’m just a fact finder) with bigeminal PVC’s. With the PVC’s I cannot really see any change in the ST segments of the normal beats. In V1 it looks like the normal beats have a rSR resemblence. In V2 the normal beats have a wider that normal complex. (>0.12) which may suggest a bifascicular block.

    Patient during intial neuro exam (unknown if vitals were taken before or prior to episode) the patient was noted as vomiting multiple times. This by itself can significantly spike blood pressure.

    Second Assessment shows improvement in neurologic function whoever the patient is presenting more lethargic than before. Patient after vomiting was given zofran. This can cause some fatigue in some people. Could be a drug interaction but less likely.

    RR: 20 Within normal limits
    Pulse: 88 Within normal limits.
    BP: 164/110 Stil ominous hypertensive crisis however MAP is lower than 150 mmHg so hypertensive encephalopathy is less likely. Also to note with the lowering of the blood pressure, there is not a significant increase in heart rate (Cushing’s Triad) which may decrease the possibility of a bleed. (does not rule it out)
    SpO2: 99 on oxygen via NRB @ 15 LPM Within normal limits.

    12-lead analysis
    There is some wandering in the baseline. Upon initial inspection you would see some T-wave inversion in the lateral leads, and ST elevation in V1 and V2. When you zoom in to V1 and V2 the QRS complex is found to be abnormal. (>0.12, measures approx 0.16) With the absence of R and r leads me to believe this could be the beginings of LBBB.

    With everything taken into consideration This is what I have come up with as to whats going on with the patient.

    I think that the patient has been having a migraine headache. The decrease in neurologic function could be due to hypoxia due to orthopnea found commonly in CHF patients. The improvement of neurologic function was due in part to supplemental oxygen administration. Blood pressure could have been influenced by a couple things. Right sided heart failure could cause elevated pressures. Also the episodes of vomiting could have played a significant role in the increases in blood pressure. Changes in ECG is really hard if not impossible to determine AMI although is a concern.

    I would treat with oxygen and zofran as stated earlier. I might consider a beta blocker to reduce blood pressure if allowed my local protocol. Other than that I wouldn’t do anything different as far as treatment is concerned.

  • Will says:

    Also pain from the migraine could also influence blood pressure

  • EMT- I Tech says:

    Just gonna do a quick interp. Well lets see the extremely high blood pressure, headache and symptoms of weakness would lead me to a possible head bleed… Also when the diastolic bp. is over a 100 the coronary arteries are not perfusing the heart very well, so you may see some ischemia ( depression in the leads).ASA if no allergy to it, high flow 02 and get to a stroke center or a hospital for a ct of the head. let me know,…….

  • arnel says:

    I concur with most response. CVA would be #1 on the list (could be big CVA or bleed). It is typical for CVA to have elevated BP and BP control will depend if it is ischemic or bleed. For ischemic everybody knows the window but this case it is difficult to know the last normal. Vomiting coulld be a sign of increase ICP. It is not typical for ischemic infarct to have edema is a few hours leading to increase ICP (most of the time about 3 or more days). It could be an ongoing bleed. The resolution of neuro findings creates also a puzzle for CVA (bleed or ischemic) but possible. Neuro findings can also be seen in seizre as Todd’s paralysis. Deterioration of LOC could be a bad sign and prepare for supporting patient. For the ecg, I was expecting global T wave inversion for neuro pt but not here. First ecg could be ectopic atrial rhythm with resolution to sinus after 5 minutes. PVC’s had an RBBB morphology with RAD and could be coming from the LAF. STE V1-V2 (with Q waves), TWI lateral leads, poor R wave progression, straigthening of the ST segment in the inferior leads, LAA in V1. Thus patient could have an old vs new MI and TWI could be due to LVH (repol abn) or ischemia in the lateral wall. So part of the work-up will also be MI. On the migraine issue (with neuro deficit), they call it complicated migraine. The work-up will still be like CVA.

  • Will says:

    In reply to EMT-I a high diastolic pressure does not absolutely suggest bleed (although it raises suspicion. The MAP is a better indicator of possible bleed. It is suggested that a MAP greater than 150 mmHg is a suggestive sign of a bleed. I’m not sure where you got the info about the diastolic being over 100 mmHg that the heart is not being perfused. I know that a MAP < 60 mmHg suggests that the heart is not being perfused. I'm not saying your wrong, but I would like some literature that solidifies your point.

    I also want to make an addendum to my first comment. If the presence of a block is new it would be a judgement call whether to treat or not to treat in the field. In the acute setting it would be easy to assume stroke which is a safe determination. If you have both evolving at the same time what do you do? Sacrifice the brain for the heart or sacrifice the heart for the brain? A decision I would quickly put on the shoulders of a physician. Going back to my previous stance I'm not entirely convinced its a stroke or TIA, although I would treat it as such until it is ruled out. I hate being wrong lol.

  • Brandon O says:

    Let’s use a “treatability” and/or a “potential harm” approach to rate the differential, folks, rather than getting caught up in what’s truly most probable. If this patient does have a primary cardiac problem, such as AMI, how hazardous is it? If it’s going to kill her, it certainly hasn’t yet, and up to a substantial degree of potential degradation we should still be able to carry her through it with supportive care. On the other hand, what if it’s an intracranial insult (whether intra or extra-cerebral)? We know that there is not only a high chance of death or permanent damage, but also that this chance increases with time and there is potential for rapid further deterioration. Given this, WHETHER OR NOT there is also a treatable cardiac abnormality, I suggest that the primary goal of treatment/transportation should be to address the stuff in the head, not the stuff in the chest. I hate to be the guy triaging bodyparts and saying “brain’s more important than heart!” but in the end I think we can agree that’s more or less the case.

    With that said, the safest route would still probably be to check with the doc. AFTER you get under way.

  • Scott says:

    If I’m thinking this is a head bleed (it’s on my list of differentials) I’m probably not going to be giving her ASA.

    Also, zofran has been known to prolong the QT interval. This pt original QTc was 442 msec’s. In addition she’s in a bigeminal rhythm. The last thing I’d want is to send her into V-tach. I’m leaning away from giving it.

  • Kelly says:

    A great case! My thoughts: an evolving subarachnoid bleed, perhaps warning signs secondary to a “leak.” ECG changes most likely have no clinical significance in the big picture but are related to the neuro-mediated response in the brain and the repeated vomiting (the actually physical act of vomiting). Not uncommon for ECG changes to resolve with SAH. I am less worried about her heart than her head and timely intervention is critical for her. Plan: treat vomiting, monitor BP closely and treat conservativley as to not increas ICP, frequently reassess neuro status

  • NHEMT-I says:

    R/O ? Brain Bleed ? Aneurysm ? CVA / TIA (TIA unlikely, doesn’t seem to resolve) ? Hypertension.

  • The guy who submitted the case says:

    The end result is a bleed. I got no word on cardiac results.

  • Issy says:

    These pieces really set a standard in the inusdrty.

  • Paul says:

    Without going into one of my long-winded tirades, No aspirin. No oxygen. Nitro if she’s with it enough otherwise use paste (for two-fold effect of addressing questionable ischemia/acute injury, and getting the blood pressure down at least marginally so, before this old codger blows another gasket), lidocaine bolus + drip (again for two-fold effect of reducing ectopy and decreasing ICP), and RSI with no hesitation whatsoever. Lidocaine + Fentanyl prior to induction -> Etomidate -> Pavulon/Rocuronium -> Diprivan drip.

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