ST Segment Elevation Myocardial Infarction
To Bite Off More Than One Can Chew
A 51-year-old man collapsed in an Internet café while eating a sandwich. He received bystander cardiopulmonary resuscitation and was in ventricular fibrillation on arrival of the emergency services. He was cardioverted at the scene and brought intubated to the cardiac catheter laboratory, bypassing the emergency room. This is now standard practice for all out-of-hospital ventricular fibrillation arrests in our hospital. His electrocardiogram on arrival exhibited first-degree atrioventricular block (PR interval, 285 ms), incomplete left bundle branch block (QRS interval, 120 ms), with anterior Q waves and ST elevation (Figure 1). His bedside echocardiogram showed a mild anterior wall motion abnormality with normal left ventricular function. We elected to perform immediate coronary angiography with a view to primary percutaneous coronary intervention. Coronary angiography revealed atheromatous but unobstructed coronary arteries, but a foreign body was noted in the right main bronchus (Figure 2). Our cardiothoracic surgical colleagues retrieved the foreign body in the cardiac catheter laboratory under fluoroscopic guidance using a rigid bronchoscope, forceps, and finally an intravascular snare catheter. The foreign body was confirmed to be a dental bridge. He was extubated on day 2 and was discharged from the hospital on day 5 with no neurological deficit. The cause of his collapse was in all probability primary respiratory arrest leading to hypoxia-induced ST segment elevation and ventricular fibrillation. His peak troponin I level was 0.93 mcg/L (normal range, <0.05 mcg/L) and creatine kinase was 154 U/L. This remarkable case illustrates that not every out-of-hospital ventricular fibrillation arrest with ST segment elevation presenting to a primary percutaneous coronary intervention center is attributable to coronary artery occlusion. This case also highlights the importance of the multidisciplinary team in the management of patients who present after out-of-hospital cardiac arrest.
- © 2013 American Heart Association, Inc.