: Dr Nachiket Vijay Potdar

“ A king, realizing his

incompetence, can either delegate
or abdicate his duties. Adoctor 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: S1S2+, 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: 1irregular 2nd degree heart block
T wave: Non specific T changes
Echocardiogram
No MR/TR AND NoAS/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 ?

RCAIschemia

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 ofrebleeding.
(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 ontogether…!
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 SAVEDTHEPATIENT?
Minister: So Humphrey, what served the situation ?
Sir Humphrey Appleby : Masterly inactivity Rather our
firm masterly inactivity Sir !!
Bernard Woolley: Yes Minister !!