A 40-year-old woman (height:5'0'' and weight: 125lbs) was brought to our Level II trauma center following a motor vehicle collision in mid-May of 2018. She was a restrained driver in the crash and denied losing consciousness. Her Glasgow coma scale (GCS) was 15. She reported abdominal pain and had abrasions over her left clavicle and lower abdomen in a seatbelt sign pattern, contusions over her right thigh and left hip and a laceration over her right knee revealing the joint. CT scan of the head, chest, abdomen, and pelvis was performed, and small foci of air was seen under the diaphragm which was indicative for small bowel perforation. A CT Scan of the head without IV contrast revealed no acute processes, including intracranial hemorrhage or cerebral contusions. The patient was emergently taken to the operating room for an exploratory laparotomy and irrigation and debridement of the right lower extremity.
The patient's prior past medical history was significant for hypothyroidism and medications prescribed were Synthroid 88 mg once daily. The patient reported that she was compliant with her medication. She denied any hypertension, cardiac, pulmonary, renal, neurological or substance use history. The patient had a normal sinus rhythm and a normal ECG with all intervals within normal limits.
On anesthesia pre-operative exam, the patient's vital signs were within normal limits. The patient underwent an exploratory laparotomy for a perforation in the jejunum and a tear in the mesentery followed by an irrigation and debridement for the open laceration in the right knee. Intraoperatively, the patient's vitals fluctuated. The patient's blood pressure ranged from 80 to 140/ 38 to 69 mmHg. The heart rate ranged from 79 to 125 beats per minute (bpm). The patient received 160mcg of phenylephrine at induction,and received 10 mg of ephedrine and 240mcg of phenylephrine when her blood pressure dropped to 90/39 mmHg.
In recovery, the patient's vital signs were as follows: blood pressure of 93/71 mmHg, heart rate of 104 beats per minute, respiratory rate of 19 breaths per minute, and an O2 saturation of 96% on room air. The patient's vital signs were monitored continuously in the post anesthesia care unit. On discharge from the recovery room, her vitals were as follows: blood pressure of 136/69 mmHg, 98 bpm, 18 breaths per minute with a 96% O2 saturation on room air.
The patient's hospital course was prolonged due to a tarsometatarsal fracture which required an open reduction internal fixation. Preoperatively, the patient's vitals were as follows: blood pressure of 116/58 mmHg, heart rate of 101 bpm, 16 breaths per minute and saturating 94% on room air. Intraoperatively, the patient's vital signs fluctuated, with her blood pressure ranging from 85 to 150/41 to 78 mmHg. Her heart rate ranged from 60 to 130 bpm. The patient received 80mcg of phenylephrine when her blood pressure dropped to 85/42 mmHg.
In recovery, the patient's vital signs were as follows: blood pressure of 135/77 mmHg, heart rate of 95 beats per minute, respiratory rate of 24 breaths per minute, and an O2 saturation of 96% on room air. The patient's vital signs were monitored continuously in the post anesthesia care unit. Her vitals were blood pressure of 123/74 mmHg, 89 beats per minute, 17 breaths per minute with a 96% O2 saturation on room air prior to discharge from the recovery room.
During her stay, her vital signs were within normal limits with the exception of episodes of sinus tachycardia as high as 119. The patient's blood pressure was well controlled, and her systolic pressure never was higher than 140.
On post exploratory laparotomy day 3, the patient developed a headache and visual changes manifesting as central blurriness. Ophthalmology was consulted and attributed the cause of visual changes to macular edema. No intervention was recommended due to their belief that it would resolve on its own. The headache and visual disturbances persisted through day 7 and now progressed to right sided hemianopsia. An MRI of the brain, MRA of the head without contrast and MRA of the neck with contrast were ordered to rule out stroke and intracranial hemorrhage. The MRA of the head and neck showed no findings, however the MRI brain showed some patchy T2 areas and diffusion hyperintensity in the periphery of both occipital lobes and adjacent cerebellar hemispheres. These hyperintensities extended superiorly on the right side into the parieto-occipital junction while the left hyperintensity appeared to spread more inferiorly and laterally (See Fig. 1). These findings were consistent with posterior reversible encephalopathy syndrome.
Over the next 3 days, the patient received an open reduction internal fixation for the tarsometatarsal fracture and was discharged to rehabilitation. The patient reports that her hemianopsia resolved in mid-July of 2018.