Old Person, Coumadin, and Head Trauma. A Bad Combination

80 something year-old woman, traveling down an escalator. Unwitnessed fall. Presents to the ED with contusion and small laceration to the back of the head. Patient mostly complaining of left knee pain. She is triaged to one of the less acute rooms.

The doctor I’m working with goes to see her, hears a bit of the story from the patient’s sister. She states the patient is more confused than usual. The patient can hold a fairly normal conversation, but does appear a bit confused. The patient can name the president of the US, but cannot remember what she ate for breakfast. She is quickly transferred to one of the trauma rooms and then sent to CT.

At CT she vomits, her heart rate slows for a moment and then starts racing. Her blood pressure climbs.

We see her as she returns from CT, and she is clearly deteriorating. She can hardly speak now. Head CT shows a significant subdural hematoma. Her heart rate is about 180, in Atrial fibrillation. O2 sats start dropping. Given Cardiozem to slow the heart rate. She’s intubated. She stabilized and then went off to neurosurgery (her sister wanted everything done to save her). I’ll find out soon what happened. The repeat head CT looked much worse, my knowledge is incredibly limited, but from what I picked up from the tone of the conversations between doctors, it didn’t seem great.

I had a great conversation with the doctor I was working with at the end of the shift about this case. He explained some of what was going on. As the patient’s hemorrhage grew, it put more and more pressure on the brain. The more the brain is squeezed, the harder it is for blood to get to the rest of the brain. So the body compensates and raises blood pressure in order to force more blood into the rest of the brain (our bodies are so cool). Her heart rate complicated matters.

As my doctor explained, a rapid heart rate can be bad for the brain as well as the heart. At a rate of 180, the patient’s heart rate needed to be slowed. (Why the rapid HR? Doc said it may have been pain.) The problem is that the medicine given to slow the heart can also drop blood pressure, which in this case could be catastrophic. If the patient’s blood pressure drops, she may end up with a stroke due to the brain not getting enough blood. That would complicate matters a bit more.

All this meant the medication given to slow the patient’s heart rate had to be administered carefully. Too much, too quickly could have lowered her blood pressure too much. The nurse giving the medication did not know this, and had to be stopped from pushing the Cardiazem too fast. The doctor was watching carefully.

Apparently intubating can also drop blood pressure, but at that point it had to be done.

Fascinating case for me and the doctor I was working with. I’m grateful for the time the physician spent explaining it to me. Tragic for the patient and family. If she survives, she may have significant neurological deficits.

UPDATE:

She did survive surgery. I don’t know anything about any deficits. Here’s to hoping she has a full recovery.

Tagged as: brain bleed, coumadin, ER, head injury, head trauma, Scribe, subdural hematoma