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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