EMS called to an 48 year old male, found collapsed on the floor with a GCS of 3, clinical presentation & observations are showed as follows:
- Resps 6 per min
- Pale and diaphoretic
- HR: - 74
- BP: - 70/49
- GCS - 3
- Sp02: 89%, 100% achieved after ventilation using B.V.M
- Blood sugar: - 4.1 mmol/I
- Not on any regular meds, and no relevant medical Hx
- Patient been fit & well up to this time
Patient was ventilated using a B.V.M on 100% O2, IV access obtained, carotid pulse was felt: which was absent, CPR was then commenced on the patient and BLS & ALS skills performed... 1st ECG capture as shows below:
ECG - 1: Patient in PEA.
ECG - 2 capture follows the one above, after return of circulation, post arrest, note the patient's blood pressure now on the top of the ECG strip.
12 - lead ECG capture on route to hospital after return of spontaneous circulation (ROSC).
This patient is now fully recovered and left hospital a week later, the medical staff at the hospital, gave the following explanations on what could have happen to this patient, do you agree with their thoughts:
- Some sort of Angina episode
- AMI
- Coronary artery spasm
Please give your opinions on the above???
Questions:
- What does the ECG's show?
- What are the likely mechanism of this?
- What are the likely causes of this?
- What are the key issues in managing this patient?
WPW associated with hypertrophic cardiomyopathy??!!!!!!
ReplyDeleteWhat lead are we looking at for the first rhythm strip? It's unfortunate that leads I, II, and III are missing from the ROSC 12-lead ECG. The first rhythm strip appears to show SR with LBBB and concordant ST-elevation (indicating acute STEMI). I think it's entirely possible that the LBBB was "new" and resolved after ROSC but the anterior injury pattern is still present. If the first rhythm strip shows lead I, then that's my answer.
ReplyDeleteInteresting case!
Tom
Thanks Tom... 1st ECG strip was taken when the patient was pulseless in PEA it's lead II, the second strip was captured shortly after on return of cardiac output... sorry about the missing leads I,II,III on the 12 lead ECG, like a clown I lost that part of the ECG!
ReplyDeleteNo worries, Mate! :)
ReplyDeleteI still think it's a "new" LBBB that resolved into a narrow complex rhythm with acute injury pattern.
Tom
I don't think it was A true PEA.
ReplyDeleteA BP & O2SAT was taken.
first strip show Sinus Rythem with A Tombstone shape QRS. it is A monitor strip & you can't base anything on it.
the 2nd strip looks like Isorythmic AV Dissociation (note the P wave going into the QRS)
the 9 leads ECG shows J point Elevation V1-V3 with tall "tent" shape T wave,(Hyperkalemia?)
it allso shows a inverted T wave (avl, v4-v6)
this T wave can be "neorologic T" (was a CT scan preformed?) or iscemic T.
I belive a cardiac marker / electrolyte blood test & a CT scan will give the final answer.
anyway this is A one bizzar ECG I give you that.
Haim
I think tthat is an early repolarisation syndrom with sudden death (probably VT) the first ECG schow sinus tachycardia with unreconized bloc (in D2 lead we cant affirm that is LBBB) after return to spontaneous circulation there is diffuse sous epicardial ischemia secondary to hypoxique arrest.
ReplyDeletethe coronag will confirm this hypothesis if normalnormal
the value of the blog goes down with personal comments, but of course the fun is there.however if personal comments r to be made then they should not be made anonymously. beside the point lets get to the ecg. ecg 1 monitor strip - lead II not much value apart from sinus rhythm with broad qrs. clinically hypotension but pulse and bp there so no PEA.
ReplyDeleteecg II- lead II- after some resus and bp still 70 sys now the QRS is narrower and you can see the pr shortiening as if QRS is marching into P so typical of a junction rhythm which is competing with the sinus impulse. Imp junctional rhythm.
ECG III- unfortunately no lead I-III. Sinus rhythm, normal PR, Narrow QRS normal QTc. ST elevation in V2-3 and Deep symmetrical t inversion in aVL, V4-6.Notice the loss of R in V5-6. this ECG suggests ACS clearly. i would suspect coronary spasm/ spontaneous thrombolysis after STEMI. coronary spasms/ spont thrombolysis may be associated with ventricular arrhythmia which may have caused the collapse.probably self terminated and there was post arrest hypotension and broadening of the QRS which settled with resusand improvement of perfusion. would like to know risk factors for CAD, h/o cocaine use.
Apical HCM also has SYM T inversions in precordial leads. they may also have LVH which is absent here. the clinical scenario and other findings in the ECG like loss of R in V5-6 suggest otherwise. in general Apical HCM has a benign prog. such T inversion along with prolongation of QTc can be seen with some drugs and cva/sah.( not the clinical scenario here).
i would be interested in knowing serial enz, echo. angio should be done. if no reversible cause is found for the arrest and CART is not consistent with ACS, then he would prob have an indication for ICD for sec prophylaxis. I am inclined to feel that ACS is prob the cause going by ECG, limited clinical info, age and ecg. even some anomalous coronary anat can behave like this. if cart and echo turn out to be normal( which is unlikely), then a TMT for ex induc arr as in catacholenergic VT,holter and isoprote infu for assessing QT prolongation, and ajmaline provokation for brugada and a good family history are essential to complete workup
Did any one give him glucose? I hope it was done just not stated on this blog. A FSG of 4, holy cow. I wonder if the low BS caused the arrest or if the arrest cased the low BS? We still treat the same and add glcose. I was just in a prehospital CE and one of the topics were BS and cardiac arest. Narcan was also mentioned. Our base hosp. wants to think of a LOC with any pt. the reason that they in the state they are to begin with. I beleive we all do that but have forgotten about the bsaics. Thiamin, narcan, and glucose for decreased LOC. I would love to know other openions.
ReplyDeleteTHX
Tammy
tammy.
ReplyDeleteWhy in the world would yo want to give a pt with a BS of 4.1 Glucose? The Glucose in the body of that pt is more than enough not to worry about it. Narcan that is a new suggestion for a decreased LOC pt that took no overdose, don't think it would work though.
Regards.
Hannes.
ILS Practitioner S.A.