Cardiac Arrest Case study / Dr. Nehad Ahmed

Subjective Data:

Subjective data refers to information provided by the patient or their family, including symptoms, feelings, and personal experiences. In the case of a cardiac arrest, the patient may be unconscious, so information is often gathered from family members or witnesses.

1.    Chief Complaint (CC):

o    "The patient collapsed and lost consciousness."

2.    History of Present Illness (HPI):

o    The patient is a 65-year-old male who collapsed suddenly while walking in the park. Witnesses reported that he clutched his chest before falling to the ground. He was unresponsive and not breathing normally. CPR was initiated by bystanders, and an automated external defibrillator (AED) was used, which delivered one shock before the arrival of emergency medical services (EMS).

3.    Past Medical History (PMH):

o    History of coronary artery disease (CAD) with a myocardial infarction (MI) 5 years ago.

o    Hypertension diagnosed 10 years ago.

o    Hyperlipidemia diagnosed 8 years ago.

o    Type 2 Diabetes diagnosed 7 years ago.

4.    Medications:

o    Aspirin 81 mg daily.

o    Atorvastatin 40 mg daily.

o    Metoprolol Succinate 100 mg daily.

o    Lisinopril 20 mg daily.

o    Metformin 1000 mg twice daily.

5.    Family History (FH):

o    Father died of a myocardial infarction at age 60.

o    Mother has hypertension and is alive at age 78.

6.    Social History (SH):

o    Smokes 1 pack of cigarettes per day for 40 years (40 pack-years).

o    Drinks alcohol occasionally, about 1-2 drinks per week.

o    Sedentary lifestyle with minimal physical activity.

7.    Review of Systems (ROS):

o    General: No recent fever or weight loss.

o    Cardiovascular: No recent chest pain or palpitations reported by family.

o    Respiratory: No recent shortness of breath or cough.

o    Neurological: No recent headaches, dizziness, or syncope.

Objective Data:

Objective data refers to measurable and observable information obtained through physical examination, laboratory tests, and diagnostic procedures.

1.    Vital Signs (upon arrival at the hospital):

o    Blood Pressure: 90/60 mmHg (hypotensive).

o    Heart Rate: 110 bpm (tachycardic).

o    Respiratory Rate: 12 breaths per minute (on ventilator).

o    Temperature: 98.2°F (36.8°C).

o    Oxygen Saturation: 95% on 100% FiO2.

2.    Physical Examination:

o    General: Unresponsive, intubated, and mechanically ventilated.

o    Cardiovascular: Tachycardic, no murmurs, rubs, or gallops. Peripheral pulses are weak.

o    Respiratory: Breath sounds are diminished bilaterally, no wheezes or rales.

o    Abdomen: Soft, non-tender, no masses or organomegaly.

o    Extremities: No edema, pulses are weak but present.

3.    Laboratory Tests:

o    Arterial Blood Gas (ABG):

§  pH: 7.25 (acidotic).

§  PaCO2: 50 mmHg (elevated).

§  PaO2: 90 mmHg.

§  HCO3: 18 mEq/L (low).

o    Electrolytes:

§  Sodium: 135 mEq/L (normal).

§  Potassium: 5.2 mEq/L (elevated).

§  Chloride: 100 mEq/L (normal).

§  Bicarbonate: 18 mEq/L (low).

o    Cardiac Enzymes:

§  Troponin I: 4.5 ng/mL (elevated, indicates myocardial injury).

§  CK-MB: 25 U/L (elevated).

o    Complete Blood Count (CBC):

§  WBC: 12,000/µL (elevated).

§  Hemoglobin: 14 g/dL (normal).

§  Platelets: 250,000/µL (normal).

4.    Diagnostic Tests:

o    Electrocardiogram (ECG): Shows ST-segment elevation in leads II, III, and aVF, indicating an inferior wall myocardial infarction.

o    Echocardiogram: Reveals reduced left ventricular ejection fraction (LVEF) of 35% (normal >55%).

o    Chest X-ray: Shows mild pulmonary edema but no pneumothorax or pleural effusion.

Assessment:

·         Primary Diagnosis:

1.    Cardiac Arrest: Secondary to acute myocardial infarction (inferior wall MI).

2.    Acute Myocardial Infarction (STEMI): Based on ECG findings and elevated cardiac enzymes.

3.    Post-Cardiac Arrest Syndrome: Including myocardial dysfunction, systemic ischemia/reperfusion response, and neurological injury.

·         Secondary Diagnoses:

1.    Hypertension: Long-standing history.

2.    Hyperlipidemia: Long-standing history.

3.    Type 2 Diabetes: Long-standing history.

4.    Coronary Artery Disease (CAD): History of previous MI.

Plan:

1.    Immediate Pharmacotherapy:

o    Oxygen Therapy: Maintained on mechanical ventilation with 100% FiO2.

o    Aspirin: 325 mg chewed and swallowed (if not already given by EMS).

o    Nitroglycerin: Administered intravenously to relieve ischemic chest pain and reduce myocardial oxygen demand.

o    Morphine: Administered intravenously for pain relief and to reduce anxiety.

o    Heparin: Intravenous bolus followed by infusion to prevent further clot formation.

o    Beta-Blocker: Metoprolol tartrate administered intravenously to reduce heart rate and myocardial oxygen demand.

o    Statin Therapy: High-dose atorvastatin (80 mg) to stabilize plaque and reduce inflammation.

2.    Reperfusion Therapy:

o    Primary Percutaneous Coronary Intervention (PCI): Immediate transfer to the catheterization lab for coronary angiography and possible stent placement.

o    Thrombolytic Therapy: If PCI is not available within 90 minutes, administer alteplase (tPA) for thrombolysis.

3.    Post-Resuscitation Care:

o    Therapeutic Hypothermia: Initiate cooling to 32-36°C for 24 hours to improve neurological outcomes.

o    Vasopressors: Norepinephrine infusion to maintain blood pressure and perfusion.

o    Glucose Control: Insulin infusion to maintain blood glucose between 140-180 mg/dL.

4.    Long-Term Pharmacotherapy:

o    Dual Antiplatelet Therapy: Aspirin 81 mg daily and clopidogrel 75 mg daily for at least 12 months.

o    Beta-Blocker: Continue metoprolol succinate 100 mg daily.

o    ACE Inhibitor: Continue lisinopril 20 mg daily to reduce afterload and prevent remodeling.

o    Statin Therapy: Continue high-dose atorvastatin 80 mg daily.

o    Aldosterone Antagonist: Consider spironolactone 25 mg daily if LVEF remains <35% after stabilization.

5.    Monitoring and Follow-Up:

o    Cardiac Monitoring: Continuous ECG monitoring for arrhythmias.

o    Laboratory Tests: Frequent monitoring of cardiac enzymes, electrolytes, and ABG.

o    Echocardiogram: Repeat in 6-8 weeks to reassess LVEF.

o    Cardiac Rehabilitation: Referral to a cardiac rehab program upon discharge.

Conclusion:

This case highlights the critical role of pharmacotherapy in the management of cardiac arrest and acute myocardial infarction. Immediate and appropriate use of medications, along with reperfusion therapy, is essential to improve survival and reduce complications. Long-term pharmacotherapy and lifestyle modifications are crucial for secondary prevention and improving overall cardiovascular health. Regular follow-up and monitoring are necessary to ensure optimal outcomes and prevent future cardiac events.