Case Of Sudden Cardiac Arrest – The Golden Hour
A 49 year old female patient was brought to the ER on 23rd January 2020 at 11:00pm by her sons on a 2 wheeler in an unresponsive state. According to her attendant she complained of sudden onset difﬁculty in breathing/chest discomfort at home around 10:00pm after which she collapsed and was unresponsive. She was apparently doing well with no acute complaints until 10:00pm and the previous couple of days.
She is known to be diabetic and hypertensive since more than 10 years, with history of Coronary Artery Disease, post PTCA and stenting done 3 years back. She is on regular medication for all the above.
On receiving at ER the patient was found to be unconscious, cyanotic and not responding to even deep pain stimulus. GCS was E1V1M1. Her carotid was absent, BP could not be recorded and GRBS – 569mg/dl, peripheries cold and saturation could not be recorded. In the absence of carotid pulse, CPR was promptly started, peripheral venous access obtained, patient was immediately intubated and after 5 cycles of high quality CPR according to ACLS protocols, ROSC was achieved and patient started on mechanical ventilation.
Post-CPR, ABG showed metabolic acidosis with ph. 7.147, Bicarbonate-11mmol/L, pO2-253, pCO2-33.7 mmHg, cLac-12.8. ECG after ROSC showed ST depressions in lateral leads with T inversions. CT brain (P) post-ROSC showed no sign of bleed or acute changes. X-Ray chest, showed haziness/patchy opacities in both lungs with p/o consolidation.
Patient was managed in the ER with ﬂuid boluses, bicarbonate correction and insulin infusion for high sugars. Empiric antibiotic coverage started, until blood reports were awaited.
She was provisionally diagnosed with recurrent CAD, cardiac arrest, post CPR status, ?DKA, ?HONC, ?LRTI and to rule out CVA. She was also on anti-platelet medication, clexane, neuroprotective medication and other supportive medication and was then shifted to MICU.
The patient responded slowly and regained consciousness within 8 hours. The patient was able to understand verbal commands and was responding to them properly.
Preliminary blood work showed, WBC – 15800, normal renal function except for RBS of >500mg/dl, Total bilirubin of 1.3 and slightly elevated SGPT and SGOT. Her serum procalcitonin at admission was 2.9. Her urine was negative for ketone bodies. Remaining blood investigations were fairly normal.
2D Echo showed dilated LV, with global hypokinesia of LV and severe LV dysfunction with EF of 25%, Grade II diastolic dysfunction, mild MR and mildly Plethoric IVC. Her TROPONIN – I was negative. She was slowly weaned off of insulin. Diuretics, Beta Blockers and Dobutamine infusion was started.
Pulmonology consultant advised for antibiotic upgradation and other supportive medication. Neurology consultation was unremarkable, with no focal deﬁcits, normal CT brain and extubation of the patient was planned accordingly.
Later she developed mild hypokalemia and hypomagnesemia and was corrected accordingly. WBC showed a decreasing trend. On 26th January 2020 patient was put on T-Piece ventilation, was monitored and then extubated in the afternoon of 26th January 2020.
The patient responded to the upgraded antibiotics and other symptomatic medication, evident in improving clinical status, reducing WBC counts and improved chest X-ray ﬁndings.
The patient underwent CAG in the afternoon of 27th January 2020 with the following ﬁndings:
CAD – DOUBLE VESSEL DISEASE (LCX & RCA) MID LAD STENT 40-50% INSTENT RESTENOSIS PATENT DISTAL RCA STENT
LCX was ruled to be the culprit vessel for the patient going into sudden cardiac arrest. Based on the above CAG ﬁndings the patient was suggested for PTCA+, STENTS TO MID LCX & MID RCA.
Due to ﬁnancial constraints the attendants did not want to undergo further management and the patient was discharged at request in a haemodynamically stable condition.
A day post extubation patient was able to speak well, could recognise her children, no focal deﬁcits were observed, memory was found to be excellent with the patient being able to completely recall the events preceding her presentation to ER. She could clearly remember her developing chest discomfort and also she being driven on a two wheeler between her two sons.
Hence it can be safe to presume that in this patient the time between cardiac arrest and the start of CPR is very narrow and one of the main contributing factors for the patient making a complete neurological recovery post cardiac arrest and ROSC following CPR. Quick recognition of cardiac arrest, prompt and high quality CPR, good ICU monitoring with timely recognition and correction of metabolic parameters, coordination between various specialties/ specialists also play a vital role in a successful outcome.
A note to the general public
-THE GOLDEN HOUR
The ﬁrst hour after the onset/start of heart attack is called the golden hour. Appropriate action within ﬁrst 60 minutes of a heart attack can reverse its effects. The Golden Hour is a window of opportunity that impacts a patient’s survival and quality of life following a heart attack. It is a critical time. This is because the heart muscle starts to die within 80-90 minutes after it stops getting blood and within six hours, almost all the affected parts of the heart could be irreversibly damaged. So, the faster normal blood ﬂow is re-established, the lesser would be the damage to the heart.