What could this have been?

Specialties Cardiac

Published

Specializes in Cardiology.

I was taking care of a frequent flyer a few days ago. This pt is in chronic CHF, awaiting an LVAD, and was ready to go home on a milrinone drip. Long story short, the pt couldn't go home for case management reasons, so stayed with us another night. Before my shift, the pt had a long run of VT that was paced out- the AICD never fired. The doc d/c'd the milrinone and ordered an amio gtt with bolus, which I started. The pt was also receiving heparin gtt, and was subtherapeutic with both that and coumadin (for underlying AF.)

Pt starts acting a little weird, unable to sit still. Lungs are dim in the bases but no crackles, no edema anywhere. O2 sat is 92 RA, 100% 2LNC. All vitals stable, BP a little soft from the amio but MAP above 60. Pt then complains of mild nausea and headache. I try to treat the nausea first before giving Tylenol. While waiting for the Zofran to take effect (which it never did) the pt says the headache is now unbearable. I call the doc to the floor STAT. Pt is neurologically intact, chatting with the doc, and walks to the stretcher. We take the pt for a head CT. On the way, the pt blows a pupil- the other suddenly pinpoint and fixed. The pt was transferred directly to the CCU. Nothing has shown up on any head CT since the initial one. Cards swears it was a CVA. Neuro says no way. The pt became confused and minimally responsive in the CCU.

I'm not back to work for a few days. I am really perplexed as to what this could be. Our first thought was hemorrhagic stroke, despite being subtherapeutic on ACs. I want to know what this was in case I see it again, but even the docs don't seem to know.

Anyone willing to toss some ideas out there? It was such a strange situation I'd like to be better prepared the next time whatever this was happens again. To be clear, I'm not looking for any advice here, just wondering if anyone has had experience with something like this and what it turned out to be, because I'm stumped.

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Specializes in Cardiology.

Awww...all the great minds here and nobody has any ideas? Guess I will have to wait till I go back to work in a couple days and see if the docs have gotten any closer to sorting this out.

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Specializes in Cardiothoracic.

This is intriguing- please keep us posted! Sorry I don't have many ideas, especially since the CT was negative for stroke. Sounds like a herniating brainstem due to increased icp or something...?

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No MRI? I have had patient scenarios where a ct didn't show anything but an MRI did

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Specializes in Cardiothoracic.

HeartRN13, now that you mention it, I've had that happen too and the pt had had a massive stroke. I forgot about it because by the time it was discovered, another nurse had the pt so I found out about it some time after...

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Adverse reaction to the Amiodarone?

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Unequal pupils are a late sign of IICP, and a bleed severe enough to cause such a severe headache and unequal pupils in such a short amount of time would certainly have been visible on a head CT. It's the embolic strokes that don't show themselves on CT for a few days, but an embolic stroke would not have caused these symptoms.

Amiodarone has several potential severe adverse reactions, two of which can cause unequal pupils. Those would be seizure and migraine.

The change in LOC later on in CCU could certainly have been a postictal state, however, I see no mention of any tonic clonic movements.

So, I'm going to go with migraine. Migraines can cause unequal pupils, and many people experience neurological symptoms with complex migraines, so I'm going with an Amiodarone induced migraine.

I'm curious to hear what the docs figured out. Please come back and let us know!

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

HUmmmm...amiodarone is a nasty...although effective drug. The pacer might not have fired if the VT was not "fast" enough.

Amiodarone can cause confusing, unequal pupils, and decreased LOC. It's not THAT common.... I'm leaning in that direction. Have the repeated the CT? they can't do a MRI because of the AICD. I would also suspect bleed... they don't always show up right away.

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Specializes in Cardiac step-down, PICC/Midline insertion.

Keep us posted! If it turns out to be amio related, that will be a very good thing to know! I give lots and lots of amio, but have never seen any problems with it other than some nasty infiltrations.

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Specializes in Cardiology.

Thanks for all the great input- it is all food for thought and one of the reasons I love this forum.

I don't have a very clear picture of what has been going on with the patient since the transfer to the critical care unit, as I no longer have a need-to-know, so to speak. I have gotten some anecdotal info as this patient was a staff favorite and people have been visiting. I believe the patient is still intubated. The milrinone was restarted the night of the transfer. The docs say it was not a seizure, not a migraine (which I never even considered, which is odd since I suffer them myself and know about the nausea and severe pain they can bring) and not a hemorrhagic stroke. Neuro said for days it was not a stroke, but I believe they are now thinking it was a TIA or embolic stroke. They are explaining away the pupils by saying the pt has had a lot of eye surgery and has something that one of them referred to as "surgery eye" which is not something I've ever heard of before and not something I can find any info on. I think it is an odd coincidence indeed that the eye thing, which is supposedly unrelated to the neuro event that clearly happened, happened as the neuro event was unfolding.

So, in the end, embolic stroke is their best guess. This always made the most sense considering the underlying AF and lab values (sub-therapeutic on heparin and coumadin both, we had recently titrated the heparin drip and were getting ready for new labs to be drawn.) But it still doesn't precisely fit the symptoms. In truth, I never saw the pupillary changes- another RN transported the pt to CT and it happened on the way. The pt never returned to my unit.

I believe they continued the amio (yes, a drug with many unfortunate side effects and adverse reactions indeed. We are actually a nationally recognized cardiac excellence hospital, so we have a LOT of cardiac pt, multiple cardiac units, and we don't use it all that often. It is definitely a drug of last resort for us, with strict policies on switching IV sites very frequently.) They restarted the milrinone drip in the CCU. They most likely restarted the heparin drip, although I am uncertain. The LVAD is probably off the table, because the pt has to be able to participate in the care of the device and it is still questionable if the pt can do that.

I'll let you all know if I hear anything more. The "answers" I have are not very satisfactory, I'm afraid.

And Esme, yes, they did repeat the CT. Nothing has showed up on any of them. Working cardiovascular care, I've certainly had pt's with strokes that didn't show up the CT, so that's nothing new, but we were hoping we would see something just to know what was going on. They were thinking the first one was so soon it just didn't show anything, but as far as I know, none of them have shown anything. Still a bit of a mystery.

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Specializes in Cardiology.

Heard through the grapevine that this pt ended up getting that LVAD, which must mean the clinical picture improved- was still in the hospital last week when I was last there. :)

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