Probable Left Main coronary artery occlusion/obstruction, with STE in aVR, alternating BBB, and arrest
Posted Nov 21 2009 10:02pm
This 59 yo male had sudden chest and abdominal pain and dyspnea. He called 911. Paramedics found him in profound distress, stating "I can't breathe". He had this prehospital ECG recorded at 0953: There is sinus tach and a wide QRS, not quite 120 ms, with wide upright R-waves in lateral leads; this is consistent with incomplete Left Bundle Branch Block. There is concordant ST depression in V2-V4, excessively discordant ST depression in I, aVL, V4-V6, and extremely excessively discordant ST elevation in aVR. ST elevation in aVR is one sign of high grade Left Main obstruction. This is STEMI. This confirms that acute coronary syndrome is the etiology of his illness and that cath lab activation is indicated. This was done.
He arrived in the Emergency department at 10:13 in severe distress. He was agitated, cool, and mottled with a weak pulse and O2 saturation of 44%. The following ECG was recorded at 10:15. There is again sinus tach, but this time with Right Bundle Branch Block and a long PR interval. Alternating Right and Left BBB is a sign of impending complete heart block below the bundle of HIS, which would lead to asystole or ventricular escape (wide and slow complex). There is persistent ST elevation in aVR and ST depression in lateral leads.
Heart rate dropped to 36 with BP 53/30. Bedside ultrasound showed a normal right ventricle but very poor LV function. After stating "I can't breathe", the patient collapsed and could not be resuscitated. No autopsy was done, so left main obstruction cannot be proven, but this is the classic clinical and ECG presentation of such pathophysiology.
Though this is STEMI, it went entirely unrecognized by the computer algorithm. The medics and physicians knew what they were dealing with but the patient died too quickly for resuscitation.
Should this patient go to the cath lab while undergoing CPR? It is the only hope for survival, and there are case reports of survival in similar situations.