Shortly thereafter, the hypotension with consequent poor perfusion of his coronary arteries resulted in severe ischemia with transmural/subepicardial ischemia, and a wide complex then eventually ventricular fibrillation.Ĭauses of Pulseless Electrical Activity (5 H's and 5 T's), as advertised by ACLS His pulses by first responders were thready, but not enough to perfuse his brain. It dissected back into his pericardium, resulting in hemopericardium and tamponade, which caused hemodynamic collapse. Thus, this unfortunate young man had an aortic dissection at a very young age. The aortic diameter is also excessive (greater than 4 cm is abnormal, here it is about 6 cm)Īutopsy showed a DeBakey 1 dissection ( from the arch all the way to the iliac bifurcation) Here is an ED ultrasound of the aorta through the suprasternal notch: Myocardial rupture from trauma (could be occult, could be due to chest compressions) Hemorrhagic pericarditis, but this would be mostly effusion with some blood, not hemopericardium and certainly not clotted blood.ģ. In spite of internal cardiac compressions, intracardiac epinephrine, several internal defibrillations for V fib, and other standard attempts at resuscitation, he could not be resuscitated. A pericardiotomy was performed and this clot was evacuated: So how would external compressions have any effect?įor cardiac compression to work, the clot must be evacuated.Īlthough there seemed little hope of recovery, a left thoracotomay was quickly performed. Even when the heart is fully beating on its own, it will arrest if there is severe tamponade because it cannot generate adequate pressures for myocardial perfusion. Of course, chest compressions are not of any use when there is massive tamponade. Here is a view during LUCAS chest compressions Here is one more brief view before chest compressions resumed: Blue arrow points to the RV, where there is full stasis of blood flow. Red arrow points to a small amount of liquid blood in the pericardium. White arrows outline a very large thrombus (clot) in the pericardium. Upon arrival, as is customary, a very brief ultrasound was performed to assess ventricular function. The patient could not be resuscitated, but was transported to the ED after about 30 minutes of full arrest. The next rhythm appears to be ventricular fibrillation. The initial rhythm is regular and wide complex, with concordant ST elevation, suggesting STEMI. Here is the rhythm strip (these are two separate tracings): Other standard cardiac arrest measures were undertaken. The patient was intubated, an ITD (ResQPod) was used. Full CPR was initiated with the LUCAS device. First responders thought they palpated a thready pulse. A 30 year old collapsed after complaining of chest pain intermittently.
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