Case 11: 3am Headaches

Medical Mystery Case 11: Chronic Headaches

A gentleman in his 40’s presents to the ED with 2 weeks of night-time headaches. He came to the ED 2 weeks prior afraid of avian flu because one of his 14 canaries had died. Evaluation at that time, including a CT of the head and an LP, was unremarkable. He presents today with 45 minutes of left arm and leg numbness without chest pain as well as ongoing headache. He recently saw a chiropractor and had neck manipulation. A CT angiogram of the neck is negative for vascular dissection, but a CBC is remarkable for polycythemia with a hemoglobin of 20. WBC and platelets are normal making polycythemia vera unlikely. The pulse ox is normal, but drops to the low 90’s when the patient falls asleep. Suspecting chronic hypoxia and sleep apnea you do an ABG with surprising results. What finding might explain night-time headaches and possible polycythemia as well?

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ANSWER:
Answer: Chronic Carbon Monoxide Poisoning

Carbon Monoxide Poisoning from “Quick Essentials“

Sx’s: Entire family or pet ill, HA, dizzy, weak, SOB, N/V, CP, palpitations

Signs: 02 sat nl. ataxia > coma, sz, AMS
Sources: Furnace, water heater, gas oven, fireplace, exhaust,

Other: methylene chloride (paint/varnish remover)
Tests: EKG, head CT. CO Level:venous OK: nl<3, smoker <10.

CO Half-life: 4.5h, 1.5h ? O2, 20m ? HBO
O2 Rx: O2: x 5h or til CO level<5-10.

HBO indications: level>25-40, AMS, acidocis, EKG, OB, LOC, neonate, Cyanide too
Other Rx: Acidosis(bicarb: pH < 7.1), Rhabdo(IVF), Sz(benzo’s), CP(NTG,O2)

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