A MYSTERIOUS DEATH IN A 21 YO HEALTHY WHITE FEMALE, AND THE LARSON MANEUVER
FROM THE BLOGOSPHERE
HYPOTENSION
Daniel Frick, DO
I
recently treated a female in her late 70s with a chief complaint of dizziness and fatigue, had HTN and recent cataract surgery. In triage she was hypotensive with BP of 70 / 35 and bradycardic ranging from 55- 60bpm, O2 sat 100 % on room air, afebrile.
I found the patient to be lethargic. Otherwise her exam was unremarkable with no focal neurologic deficits, cardiac and pulmonary exam unremarkable, and no abdominal pain. Her husband was in the room and states that they were on their way to a high school graduation and she began to feel dizzy and became lethargic. She had not been sick recently and before this morning she was at her baseline. Yesterday her blood pressure was 180 / 95 when she checked at home-she typically runs high. They reported no changes to her medications: metoprolol succinate 100mg po daily and a baby aspirin.
As I talked to the husband he went on to explain that she recently had cataract surgery on her left eye and this morning had a follow up appointment with her ophthalmologist. The ophthalmologist said that
the pressure in her eye was high and she received drops in her eye to bring the pressure down, but the husband could not remember the name of the drops.
So I obtained a CBC, CMP, TSH, Urine, Chest Xray, EKG, Troponin and a head CT to complete my little old lady Altered Mental Status workup- obviously the differential diagnosis for AMS in the elderly is vast. While I waited for her results I called her ophthalmologist to see what drops she had received. Answer: Alphagan( alpha agonist), Trusopt( carbonic anhydrase inhibitor), and 3 drops of Timolol( beta blocker).
I discussed with him the possibility of the Timolol with her morning metoprolol as potentially causing her hypotension and bradycardia. He stated he had never seen that happen in his many years of practice but it is theoretically possible. A quick lit search confirmed that hypotension can occur in as many as 10 % of patients using Timolol eye drops, which to me was a surprisingly high number.
Her labs and imaging returned unremarkable and her EKG showed sinus bradycardia with a rate of 57. She received 2L of Normal Saline and we watched her for about 5 hrs. Throughout her stay her blood pressure steadily increased and at the time of her discharge she was 135 / 86 with a heart rate of 74 and she was back to her baseline and much more awake.
I thought this was an interesting case as it seems relatively rare for topical eye drops to result in systemic side effects. A quick literature search brought up multiple case reports of patients having symptomatic bradycardia and even syncope resulting from Timolol use.
This is definitely something to keep in mind with an elderly or frail patient with acute angle glaucoma who is already on beta blocker therapy. Be sure to make the patient aware of the possibility of side effects including hypotension, bradycardia, fatigue, and even syncope.
Dr. Daniel Frick is a PGY3 Emergency Medicine Resident at the University of Louisville Hospital.
A MYSTERIOUS DEATH IN A 21 YO HEALTHY WHITE FEMALE, AND THE LARSON MANEUVER
Brian Ferguson, MD
My wife is at work at a hand surgery pre-op care clinic. It is her birthday. In walks a middle-aged male who is about to have tendon reconstruction after he sustained a crush trauma, and is excited about the possibility of returning to work. He is slightly abrasive and somber, despite the prospect of receiving the surgery.
My wife asks him if he is concerned about the procedure, asks if he is feeling well, asks if there is anything she can do to help. With a quiet manner he states all is well. To make discussion my wife states today is her birthday and she is excited to celebrate when she
gets home. He smiles and states today is also his daughter’ s birthday. She was born the same year as my wife. He states today is always a rough day for him because she passed away in an emergency room 7 years ago at 21 years of age.
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