Case presentation of cardiac arrest survivor

1. Dr Md Seebat Masrur
Indoor Medical Officer
Department of
Cardiology, TMC and RCH
Welcome to today`s
Case presentation

3.  A 45 years old
male admitted
into
cardiology
department
with severe
central chest
pain and
sudden loss of
consciousness.

4. Particulars of the Patient:
Name: Mr. Amzad Hossain
Age: 45 years
Sex: Male
Religion: Islam
Marital status: Married
Occupation: Service holder
Address: Ghoria, Rohobol, Shibganj, Bogra.
Date of Admission:24.04.2021
Date of Examination:24.04.2021
Department: Cardiology

5. Presenting Complaints
1. Chest pain for 6 hours.
2. Sudden Loss of consciousness for 5 minutes.

6. History of Present illness
According to the statement of the patient’s
attendant, he was reasonably well 6 hours back.
Then he felt sudden central chest pain, which
was severe, compressive and squeezing in
nature. Pain radiated towards left arm and
associated with profuse sweating, nausea &
vomiting. There was no aggravating or relieving
factor. No history of cough, fever or
breathlessness.

7. Continued…….
While Emergency medical officer was
examining, the patient suddenly collapsed.
Basic life support was started immediately and
measures to transfer the patient to CCU were
taken outright. At CCU basic life support was
continued while making a quick assessment. At
CCU, his pulse was not palpable, BP was not
recordable, respiration was agonal, blood sugar
was within normal limit,SP02 54%, pupil was
mid-dilated & response to light was sluggish,
GCS 3/15.Immediately Defibrillator monitor
was attached to the patient and monitor
showed Ventricular Fibrillation. Then advanced
cardiac life support was started.

9. Continued…
DC shock was given at 200J and CPR (30:2)
continued for 2 minutes. But ventricular
fibrillation did not reverted to sinus rhythm.
Again, DC shock at 200J was given and
CPR(30:2) continued. Ventricular fibrillation
reverted to sinus rhythm. Then patient`s
pulse became palpable which was feeble, BP
was 60/40mm hg, respiratory rate 12
breaths/min,SpO2 90%,GCS 7/15. The
patient was still unconscious and frequent
seizure occurred.

10. History of Past illness:
He had no history of Ischemic Heart
Disease, Hypertension, Diabetes
mellitus, Cerebrovascular disease or
any other comorbid condition.

11. Drug HISTORY
There was no significant drug history.

12. Family history
His parents are alive. He has one brother,
two sisters and one child. His father and
elder brother were suffering from
Ischemic Heart Disease.

13. Socio-economic history:
He came from middle class family.

14. Personal history:
He is chain smoker and smokes about 20 sticks
per day for 15 years. He is nonalcoholic & non
betel nut chewer.

15. Immunization history:
He was partially immunized.

16. General Examination:
 Appearance: Ill looking
 Decubitus: lying flat
 Body build: Average
 Co-operation:Nonco-
operative
 Nutrition: Average
 Anemia: Absent
 Jaundice: Absent
 Cyanosis: Absent
 Clubbing: Absent
 Oedema: Absent
 Koilonychia: Absent
 Leukonychia: Absent
 Pigmentation: Absent
 Dehydration: Absent.

17. Continued:
• Body hair:
Normally
distributed
• Deformities:
Absent
• Lymph node: Not
palpable
• Thyroid gland:
Not enlarged
JVP: Not raised
Pulse: Not palpable
BP: Not recordable
Respiration: Agonal
respiration
Temperature: 98 F

18. Systemic examination:
A. Cardiovascular system:
1. Arterial pulse : All arterial pulses were not
palpable

19. Continued:
2. Blood pressure: Not recordable
3. JVP: Not raised
4. Examination of precordium:
a)Inspection:
 Size and shape: Normal
 Visible pulsation: Absent
 Epigastric pulsation: Absent
 Venous engorgement: Absent
 No scar mark, no deformity.

20. Continued:
b) Palpation:
 Apex beat: Not palpable
 Thrill: Absent
 Left parasternal heave: Absent
 P2: Not Palpable
 Any pulsation in Aortic area: Absent
 Epigastric pulsation: Absent
 Enlarged, Tender Liver: Absent

21. Continued:
C) Percussion: Not done
D) Auscultation:
1st heart sound: Not Audible
2nd heart sound: Not Audible
Added Sound: Absent
Bilateral basal crepitation: Absent

22. B.RESPIRATORY
SYSTEM:
 Respiratory rate:3-5 agonal breaths per
minutes.
 Inspection:
 Shape of the chest: Elliptical shaped
 Movement of the chest: Silent Chest
 Intercostal indrawing: Absent
 Subcostal recession: Absent
 Scar mark: Absent
 Any visible pulsation : Absent

23. Palpation:
 Position of trachea: Centrally placed
 Position of apex beat: Not palpable
 Chest expansion: Not expanding
 Chest expansibility: Not expansible
 Vocal fremitus: Not performed

24. Percussion
 Percussion note: Resonant
 Liver and cardiac dullness was in normal
area

25. Auscultation:
 Breath sound: Absent
 Vocal resonance: Not performed
 Added sound: Absent

26. Alimentary system
Examination of oral cavity: Gum, teeth,
tongue, buccal mucosa –normal
Abdomen proper:
Inspection: normal
Palpation:
Superficial palpation:
•Tenderness: Absent

27. Deep palpation:
• Liver: Not palpable
• Spleen: Not palpable
• Kidney Not ballotable
• No lump or mass
• Genitalia :normal

28. Continued…
 Percussion: Percussion note was tympanic
No shifting dullness.
 Auscultation: Bowel sound normal
Bruits: Absent
 Digital Rectal Examination: Not Done

29. Examination of Nervous
system
 GCS E1 M1 V1(3/15) after defibrillation 7/15
 Higher psychic function : Cannot be
performed as the patient was unconscious
• Orientation :
• Intelligence :
• Speech :
• Consciousness :
• Memory :
• Cranial nerves :

30. Continued…
 Cerebellar function :
 Motor function :
 Co-ordination of movement:
 Reflexes :
 Involuntary movements :

31. Continued…
 Signs of meningeal irritation :
 Neck rigidity : Absent
 Kernigs sign : Absent
 Brudzinski’s sign : Absent

32. Other systemic examination revealed no abnormal
findings.

33. Salient features:
Mr Amzad hossain 45 years old male,
normotensive, nondiabetic, smoker,
nonalcoholic, non beetle nut chewer, with a
positive family history for IHD was admitted in
this hospital with the complaints of chest pain
for 6 hours, which was severe, compressive
and squeezing in nature. Pain radiated towards
left arm and was associated with profuse
sweating, nausea & vomiting. There was no
aggravating and relieving factors. No history of
cough, fever or breathlessness.

34. Continued…
While Emergency medical officer was examining,
the patient suddenly collapsed. Basic life
support was started immediately and the patient
transfer to CCU while maintaining CPR. In CCU
basic life support was continued and the
diagnosis of Cardiac arrest in the form of VF
was confirmed by ECG. Advanced cardiac life
support was started. At first DC shock at 200j
was given and CPR continued for 2 minutes. But
VF not reverted to sinus rhythm. Again DC shock
at 200j was given and CPR continued. VF
reverted to sinus rhythm and patient’s pulse, BP
& respiration reappeared. The patient was still
unconscious and frequent seizure occurred.

35. Continued…
Patient was defibrillated with DC shock of
200J and CPR (30:2) continued. But rhythm
still showed ventricular fibrillation. So
again, 200J DC shock was given and
CPR(30:2) continued. VF reverted to sinus.
Then upon assessment patient`s pulse was
feeble, BP was 60/40mm hg, respiratory
rate 12 breaths/min,SpO2 90%,GCS 7/15.
The patient was put on inotrope. The
patient was still unconscious and frequent
seizure occurred over the next 3 hours.

36. Continued:
Cardiovascular system: All arterial pulses
were not palpable. Examination of
precordium: Inspection-there were no
visible pulsation, no scar, no deformity.
Palpation- not palpable. There was no thrill,
left parasternal heave absent,P2 not
palpable, No pulsation in Aortic area and
epigastric pulsation absent. On auscultation
– 1st and 2nd heart sounds were not audible,
No added sound found, there was no basal
crepitation.

37. Continued:
Respiratory system examination: on inspection-
patient chest was silent, palpation trachea was
centrally placed, no chest expansion noticed,
percussion note was tympanic ,auscultation- breath
sound : absent, no added sound found. Alimentary
system, nervous system and other system revealed
normal findings.

38. Clinical diagnosis:
So, my clinical diagnosis is-
Cardiac Arrest due to Acute Coronary
Syndrome.

39. Differential Diagnosis (D/D):
1. Aortic Dissection
2. Pneumothorax

40. INVESTIGATION
1. ECG:
• On Monitor: Showed Ventricular fibrillation
• ECG:AMI(Ant+Inf) {After defibrillation}
2. CXR A/P view: Normal findings
3. RBS:5.8 mmol/L
4. CBC: Hb%- 13.6 gm/dl, ESR -19 mm in 1st hr, TC-
12700/cmm, Neutrophil- 80%
5. S. Electrolyte: Normal value
6. S. Creatinine :1.28 mg/dl
7. Troponin I: 9.47 ng/ml

41. Continued…
 RT PCR for covid 19 test: Negative
 S Lipid profile: Normal
 Urine R/E: Normal

42. Cardiac Monitor(Before
defibrillation)

43. Cardiac Monitor(After
defibrillation)

44. ECG

45. CXR
A/P
view
Normal Chest
Skigram

46. ECHO 2D
Comments:
• LV Dialated, Antero-septal
wall hypokinesia.
• TR(Minimal)
• Mild LV Systolic Dysfunction
LVEF 50%

47. Final Diagnosis
So final diagnosis is-
Cardiac Arrest in the form of
Ventricular Fibrillation due to Acute
Myocardial Infarction(Ant+Inf)

48. Treatment:
On admission
Immediate management:
1. Airway clearance by sucker machine
2. Maintenance of breathing and O2
supplementation via AMBU Bag
3. Maintenance of circulation by external cardiac
massage and IV channel access
4. Cardiac defibrillation twice(200J and 200J)

49. Pharmacological Management
 Inj Dobutamine-I/V @ 3 ml/Hr via syringe
pump
 Tab Aspirin- Loading and maintenance dose
 Tab Clopidogrel- Loading and maintenance
dose
 Tab Atorvastatin 40mg-0+0+1(B/M)
 Tab Trimetazidine 35mg-1+0+1
 Inj Enoxaparin 60mg-1 PFS S/C was given
 Tab Frusemide+ Spironolactone
 Tab Phenytoin 100mg-1+1+1

50. Continued…
 Inj Diazepam 10mg-I/V slowly stat
 Inj Phenobarbitone 200mg-1 Vial I/V stat
 Inj Levetiracetam 500mg-1 amp I/V slowly
and TDS
 Inj Pethidine 100mg-25 mg I/V stat
 Inj Prochlorperazine 12.5mg-1 amp I/V stat
 Inj Pantonix 40mg-1 vial I/V stat & BD
 Inj Ceftriaxone 1gm-1 vial I/V stat & 12 hrly

51. Treatment on Discharge
 Tan Aspirin+Clopidogrel…0+1+0(After Meal)….Continue
 Tab Amiodarone 200mg….. ½+0+½ ……………….Continue
 Tab Atorvastatin 40mg…….0+0+1(before Meal)..Continue
 Tab Nitroglycerin 2.6 mg….1+0+1+0………………….Continue
 Tab Trimetazedine mr 35mg…1+0+1……………………Continue
 Tab Furosemide+Spironolactone 20/50mg..1+0+0..Continue
 Tab Pantoprazole 20 mg…1+0+1(Before meal)…….Continue
 Tab Bromazepam 3 mg….0+0+1…………………………..Continue
 Nitroglycerin Spray..2 puff under the tongue……..If severe
central chest pain

52. Advice
 Advice for Coronary Angiography.

53. After A Month
Patient went to National heart foundation and research center

54. Coronary
Angiogram report
LAD Type IV vessel & 80-
85% Stenosis in its proximal
segment.D1 has got 80-90%
stenosis in its proximal
segment.
Comment-Single Vessel
Disease
Recommendation-PCI to
LAD

61. Coronary
Angioplasty &
Stenting
LAD proximal(80-
90%) Type C lesion
Stent
used:XIENCE-
PRIME-3.00*18mm

62. Post PCI ECG

63. ECHO-2D
Comments-S/P PCI
Ischemic Heart Disease with
Regional wall motion
abnormality present
Mild MR
Mild LV Systolic Dysfunction
LVEF= 43%

64. Ongoing Treatment
 Tab Aspirin 75 mg….0+1+0(After Meal)…….Continue
 Tab Prasugrel 10 mg 0+0+1(After Meal)…..Continue
 Tab Atorvastatin 20mg..0+0+1(Before meal)..Continue
 Tab Metoprolol 25 mg..1+0+1…………..Continue
 Tab Ramipril 1.25mg…0+0+1………….Continue
 Tab Trimetazidine MR 35 mg…1+0+1……Continue
 Tab Furosemide+Spironolactone 20/50…1/2+0+0+…Continue
 Tab Prantoprazole 20mg…1+0+1(Before Meal)….1 Month
 Tab Clonazepam 0.5mg..0+0+1……..7 days
 Anril Spray..2 puff x Under tongue….If Chest pain

65. Prognosis
 Acute MI has a high mortality. At least one
third of the patient die before reaching
the hospital & another 40-50% are dead
upon arrival. Another 5-10% die within the
first 12 months. Readmission rate is about
50% with first 12 months.
 The overall prognosis actually depends on
extent of muscle damage. That's why TIME
IS MUSCLE.

66. Prognosis
 Incidence of Shockable rhythm is
24%.Survival rate is over 30%
 Whereas in Nonshockable rhythm
incidence is 76%.Survival rate is
less than 10%
 Furthermore, decrease in survival
by 8-10% for every minute delay
after collapse to defibrillation

67. Key message
The overall mortality &^morbidity can
be reduced by providing Optimum
care at Right Time in Right place.

71. Cardiac Monitor