A 39 y.o. male presented with L arm and L leg weakness after a nurse started his IV.
Why did this happen?
Why did this happen?
Our patient had a stroke from an air embolus. The clubbing of his hands was a clue to his congental heart disease. His stroke could have been prevented by using a Pall filter, a device that attaches to the IV and filters out air.
The following is a brief outline of treatment of single ventricle; his congenital condition. The treatment was developed because the problem was once universally fatal. Now a series of operations are performed which enable 40-50% to live to adulthood.
The first operation is called the Norwood and creates a pathway of blood from the heart to the body. A large communication is made between the atria to allow oxygen-rich blood from the lungs to pass through the heart and created a flow of blood from the heart to the lungs. THE RIGHT VENTRICLE IS MADE TO PUMP BLOOD TO THE BODY. A connection is made between the subclavian and the aorta. (the Blalock Tausssig shunt). As a result blood from the lungs enters the L atrium crosses to the R atrium through the ASD and mixes with unoxygenated blood from the body. This is done either immediately after birth or up to two weeks later. Sats remain low.
2. The second operation is called the Glenn. It takes the blood from the upper body, the SVC, and connects it directly to the pulmonary artery. The shunt between the aorta and pulmonary artery is removed. THE WORK-LOAD IS THE HEART IS EASED BECAUSE THE HEART NO LONGER HAS TO PUMP BLOOD TO THE LUNGS FROM THE UPPER BODY. Because the blood from the lower body still mixes with the oxygenated blood the sats remain low.
1. The third operation is called the Fontan. In this operation the IVC is connected to the lung circulation. THE SINGLE VENTRICLE NO LONGER HAS TO PUMP BLOOD TO THE LUNGS. A baffle is left in the R atrium which opens if the pressure in the venous circulation gets too high. It is through this baffle that air emboli can pass.
Our patient was given a Pall filter( .2 micron) in the ED and successfully recovered from his stroke. Of note a PE protocol CT cannot be done through this filter because it delays the administration of contrast.
Pall filter
Clubbing is usually thought to be related to decreased oxygen levels. With hypoxia extrapulmonary shunting of blood occurs allowing large megakaryocyte to bypass the pulmonary circulation. When they gain access to systemic circulation they become impacted at distal sites and endothelial growth factor is released. This growth factor is thought to be what causes clubbing. It is not clear why other diseases like celiac disease and crohn’s are associated with clubbing but it is thought that inflammation triggers a platelet growth factor. Rarely, the cause of clubbing is genetic as in pachydermoperiostosis which not only causes clubbing but wrinkling of the face and scalp.
pachydermoperiostosis
Krugh M, Vaidya P. Osteoarthropathy hypertrophic. StatPearls. Treasure Island, FL: Statpearls Publishing, 2019.
Callemeyn J, Van Haecke P, Peetermans W, et al. clubbing and hypertrophic osteoarthropathy: insights in diagnosis, pathophysiology and clinical significance. Acta Clin Belg. 2016;71(3):123-30.
Martinez-Lavin M, Exploring the cause of the most ancient clinical sign of medicine: finger clubbing. Semin Arthritis Pheum. 2007 Jun;36(6):380-5.
University of Michigan Congenital Heart Center