This is the conclusion to 60 year old male CC: Sudden cardiac arrest.
As you may recall the resuscitation was implemented using the choreographed or "pit crew" model.
This is characterized by:
- Skills and competencies
- Teamwork and communication
- Best practices
Special emphasis is placed on:
- Minimally interrupted chest compressions
- Controlled ventilations
- Appropriate timing (e.g., pre-charging the defibrillator, shocking every 2 minutes, miminizing delays between stopping compressions and shocking)
This is not meant to miminize the importance of the chain-of-survival, including early activation of 9-1-1 and bystander CPR. Those links were intact for this case and that is extremely important.
As you might recall return of spontaneous circulation (ROSC) was achieved, the patient was loaded for transport, and a 12-lead ECG was captured.
Let's take another look.
The obvious question (and the one I usually ask) is whether or not this 12-lead ECG shows STEMI.
However, before we look at that, let's review some important comments from:
Regional Systems of Care for Out-of-Hospital Cardiac Arrest – A Policy Statement From the American Heart Association. Circulation 2010;121:709-729
Up to 71% of patients with cardiac arrest have coronary artery disease, and nearly half have an acute coronary occlusion. There is a high incidence (97%) of coronary artery disease in patients resuscitated from OOHCA who undergo immediate angiography and a 50% incidence of acute coronary occlusion. However, the absence of ST elevation on a surface 12-lead electrocardiogram after resuscitation of circulation from cardiac arrest is not strongly predictive of the absence of coronary occlusion on acute angiography (emphasis added). A case series of patients with unsuccessful field resuscitation suggested that in such patients, VF is more likely to be due to coronary disease than is asystole or pulseless electric activity. An autopsy study compared case subjects who died within 6 hours of symptom onset due to ischemic heart disease and who were not seen by a physician within 3 weeks with control subjects who died within 6 hours of symptom onset due to natural or unnatural noncardiac causes…Collectively, these studies suggest that patients who are resuscitated from out-of-hospital VF have a high likelihood of having an acute coronary occlusion (emphasis added).
The feasibility and efficacy of primary PCI in patients who survive cardiac arrest with STEMI have been well established. The combination of mild therapeutic hypothermia with primary PCI is feasible, may not delay time to start of primary PCI in well-organized hospitals, and is associated with a good 6-month survival rate and neurological outcome…Patients resuscitated from OOHCA with STEMI should undergo immediate angiography and receive PCI as needed. Immediate coronary angiography is reasonable for patients resuscitated from VF and may be considered in patients resuscitated from other initial rhythms who do not have a clear noncardiac cause of cardiac arrest (emphasis added).
Does the first 12-lead ECG look like it might be an acute anterior STEMI? I would have to say yes (the 12-lead ECG captured on arrival at the hospital does not look like a classical STEMI — we'll get to that in a minute). However, my question for you is, should it matter?
The patient has been resuscitated from sudden cardiac arrest of presumed cardiac etiology. That alone is enough reason to send the patient emergenty to the cardiac cath lab, IMHO. That (along with other important post-resuscitation care like therapeutic hypothermia and ICDs) is why the AHA is advocating regional systems of care for out-of-hospital cardiac arrest.
Now let's look at the 12-lead ECG acquired on arrival at the hospital.
Now rather than ST-elevation in the anterior leads we see a different ECG abnormality that is also concerning. Namely, ST-elevation in lead aVR and V1 with ST-depression in leads I, II, III, aVL, aVF, V3, V4, V5 and V6.
(Side note: remember the "rule of proportionality" when you look at ST-elevation or ST-depression. The QRS complexes in the limb leads are very small. Hence, even a tiny bit of ST-elevation or ST-depression is significant).
This could indicate left main coronary occlusion, 3-vessel disease, or subendocardial ischemia. Again, this is just academic since you could argue that all patients resuscitated from VF arrrest should be emergently cathed.
On arrival at the hospital the attending ED physician grabbed the Code Summary out of the treating paramedic's hand and saw this rhythm strip.
As a happy coincidence this rhythm strip (which was captured in monitor mode) exaggerated the ST-elevation in lead V1. Perhaps the ED physician would have called the Code STEMI anyway. At any rate, the Code STEMI was called immediately.
Angiography revealed severe atherosclerotic disease that was not amenable to catheterization. The patient was taken emergently to the OR where he received a 5-vessel CABG.
The patient was discharged from the hospital a week later neurologically intact.