: Dr Nachiket Vijay Potdar

“ A king, realizing his

incompetence, can either delegate
or abdicate his duties. A doctor can
do neither. If only they could see
the paradox, they would
understand the dilemma.”
89 yr old retired taxi driver, South-Asian origin
Overweight
h/o: IHD, CKD and Recent SDH s/p: conserved
p/c: Light headedness since 4 days with some
headache
Epigastric discomfort with Nausea
Increased frequency of urination during night
Increased pedal and peripheral edema
On Examination
PR- 40/m
RR- 16/m
BP- 115/70 mmHg
RS: bi-basal creps +
CVS: S1 S2+, no murmurs
Abdomen: soft, non-tender, no organomegaly
CNS: GCS: 15/15, no focal neurological deficits
Hb- 100 g/l ( MCH- 28, MCV- 87 )
WBC- 6.9 ( 75/14/5/5/1)
Platelets- 155
Urea- 9.2
Creat- 150/107
Na- 135, K-4.4, Glucose: wnl
CRP- 5.4 ( 17th March )
LFT- wnl
VBG- wnl
Coagulation profile-wnl
ECG
Rate- 40/m
Rhythm: Sinus Bradycardia
Axis: Normal
QRS Complex: Narrow Complex with occasional
ventricular ectopics, ? Infra-nodal escape rhythm
2: 1 irregular 2nd degree heart block
T wave: Non specific T changes
Echocardiogram
 No MR/TR AND No AS/PS
 RWMA+
 LV EF: 35%
CT- Head (17th March 2018 )
Shallow acute on chronic Subdural Hematoma,
No SOL,
No midline shift
Marked cortical atrophy
Problem:
Signs and Symptoms due to SDH Or Cardiac Issue ?

RCA Ischemia

Bradycadia

Syncope

Acute on chronic Subdural Hematoma?

Or

Subdural Hematoma

Headache and Light headedness (associated with

unrelated 2:1 irregular 2* heart block )
What’s Next ?
 Trops !!
Trop- 858 ( March 17th )
Could raised Trop levels be due to SDH ?
 Unlikely, though SAH has proved association.
 (https://www.sciencedirect.com/science/article/pii/S2
221618914600743)
NSTEMI !!!
Acute on Chronic SDH
No Anticoagulants And hence no PCI or CABG
Anti-platelets ?

Neurosurgery opinion: Conserve.

Anticoagulant medications are associated with
increased rebleeding risk in older adults with cSDH.
However, antiplatelet medications are not associated
with increased risk of rebleeding.
(https://www.ncbi.nlm.nih.gov/pubmed/28411235)
No ACE-Inhibitors: AKI ?
No B-Blockers: Bradycardia ?
At least Statin to be continued !

Aspirin- 75 mg
Atorvastatin- 80 mg
“Life's under no obligation to give us what we expect.
We take what we get and are thankful it's no worse than it is.”
: Margaret Mitchell, Gone with the Wind !
Trop I: 1300/ 855 (21st March )

Second anti-platelet agent ?

CT Brain: Rebleed within right fronto-parietal SDH

with mild pressure effect.

With-hold Aspirin
Still cries the soul …!
If we can hold on together…!
Temporary Pacemaker Implantation
Worsening ischemia
Irregular block- prone to asystole
Post TPI
“Life will find its way”
( : Dr Michael Crichton, MD Internal Medicine,
Author of The Jurassic Park ! )
Trop I: 160/1300
CT Brain: No new changes
Patient is now symptom free and hemodynamically
stable.

Planned for subsequent review for delayed PCI

Current Medications
 B blocker
 ARB
 Statin
WHAT SAVED THE PATIENT ?
Minister: So Humphrey, what served the situation ?
Sir Humphrey Appleby : Masterly inactivity Rather our
firm masterly inactivity Sir !!
Bernard Woolley: Yes Minister !!