Collapse, Ventricular Tachycardia, Cardioverted, Comatose on Arrival. OMI is a clinical diagnosis.

A middle-aged woman cried out, then collapsed.  She had bystander CPR.  First responders palpated a pulse.  Paramedics found her to be in Ventricular Tachycardia.  She underwent synchronized cardioversion.On arrival, she had this ECG:What do you think?There is sinus rhythm. The ECG shows unequivocal ST Elevation in I and aVL, with reciprocal inferior ST Depression, and also STE in V3-V6.  There is unequivocal subepicardial (transmural) ischemia on this ECG.  This is probably a proximal LAD occlusion, right?Not so fast!!This patient dropped to the ground, and in spite of VT with a pulse (not VF without pulse), she remained comatose and was a GCS of 3.  This does not make sense.  If the patient had a pulse, there should have been brain perfusion and she should not be so deeply comatose.I saw this patient (many years ago, before starting blogging in 2008) and thought, " this could be intracranial bleed with a pseudoSTEMI pattern. "  So we did a head CT before activating the cath lab and there was a huge spontaneous aneurysmal subarachnoid hemorrhage.We must have done a bedside echo, but I don ' t remember what it showed (was there apical ballooning?)Unfortunately, the patient went on to brain death.Learning Point:Patients who present deeply comatose after cardiac arrest do so because there is a brief (at least several minutes) period of no cardiac output and thus no perfusion of the brain.  If there was no such period of nea...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs