Chapter 6: Acute Coronary Syndromes
A 64-year-old-man with a history of CAD with multiple PCI in the past and DM presents to the ED after becoming unresponsive while at a dinner party. Cardiopulmonary resuscitation is initiated by a guest, and when EMS arrives on the scene, he is found to the have the initial rhythm in Figure 6-7A. He is intubated and defibrillated several times, and achieves return of spontaneous circulation (ROSC) within 10 minutes. In the ED, he is unresponsive, and his physical exam is notable for normal S1 and S2 with an S3 gallop, jugular venous pressure (JVP) of 10 cm, rales in bilateral lower lung fields, and cool distal extremities. While in the ED, he has an episode of pulseless ventricular tachycardia and is cardioverted immediately with ROSC within a minute. Intravenous amiodarone is initiated, as is norepinephrine for persistent hypotension. His vitals are as follows: BP of 80/60 mmHg, heart rate (HR) of 110 beats/min, respiratory rate (RR) of 18 breaths/min, blood oxygen saturation (SpO2) of 90% on room air with a fraction of inspired oxygen (FiO2) of 100%. The ECG obtained in the ED is shown in Figure 6-7B. A computed tomography (CT) scan of his head in the ED reveals no acute intracranial pathology. What is the next best step for the patient?
Figure 6-7. (A) Strip obtained by emergency medical services. (B) Electrocardiography strip from the emergency department.
A. Initiate targeted temperature management
B. Urgent electrophysiology consult for arrhythmia management
C. Administer aspirin, ticagrelor, rosuvastatin, and heparin bolus, and activate cardiac catheterization laboratory
The patient in the clinical scenario is presenting with ventricular fibrillation, and his post–cardiac arrest ECG is concerning for acute ischemia in the inferolateral coronary territory. The most appropriate next step for this patient is the initiation of hypothermic protocol, now referred to as targeted temperature management (TTM), and prompt coronary angiogram to facilitate revascularization. Therefore, both choices A and C are correct. The patient’s initial rhythm on presentation is likely a result of his ischemia; therefore, Advanced Cardiac Life Support protocols should be followed for management of the patient’s arrhythmia, and not urgent consultation of the electrophysiology service.
In patients post–cardiac arrest, neurologic dysfunction and myocardial dysfunction are the major contributors to mortality. Post–cardiac arrest care involves optimization of cardiopulmonary function to maintain adequate organ perfusion as well as employing neuroprotective measures to improve outcomes. Several studies have demonstrated that in patients with out-of-hospital cardiac arrest due to VF, induced hypothermia improves neurological outcomes., The prevention of neuronal death ...