STEMI complicated with cardio-respiratory arrest, cardiogenic shock and Mendelson’s syndrome

Introduction: We present the case of a 58 year old patient, non-smoking, normal weight, normotensive admitted in CCUBCVA by emergency transfer from a regional hospital. During the day the patient called 112 accusing intense chest pain and dyspnea. At ambulance arrival the patient was conscious, but during transport he suffers cardiac arrest with ventricular fibrillation preceded by seizures accompanied by emesis and probable aspiration in the airways. Advanced life support measures were performed – chest compressions, cardioversion with 360 J, adrenaline 1 mg repeated up to total of 3 mg, dopamine continuously, endotracheal intubation and mechanical ventilation. Methods: At arrival, the patient was in serious condition, mechanically ventilated, sedated with midazolam, hypotensive under inotropic support. In ER the diagnosis of STEMI was established followed by administration of 5,000 IU heparin bolus then continuous infusion of 1,000 IU/h, 300 mg clopidogrel and 250 mg aspirin and the decision to call for air transfer through SMURD to CCUBCVA. We confirmed the diagnosis of STEMI Killip IV, Forrester IV with ECG pattern of “mid-anterior infarction”. Echocardiography described akinesia of IVS, anterior wall and severe hypokinesia of 2/3 apical inferior and lateral wall, with LVEF ~15%, minimal mitral regurgitation, no pericardial fl uid. Coronary angiography revealed a 40% stenosis in LAD segment 2, occlusion of fi rst diagonal, normal RCA and LCX. Results: PCI with stent implantation was performed on first diagonal obtaining TIMI 3 flow. Post-PCI worsening of hemodynamic status under increased inotropic support imposed the implantation of an intra-aortic balloon pump with consecutive improvement of tissue perfusion during the first 24 hours. Due to favorable evolution with improved net clinical parameters, biological and echocardiographic (LVEF ~ 40 – 45%), the balloon was removed in day 4 of ICU. The patient’s condition was aggravated by the development of early signs of Mendelson’s syndrome, and ventilator associated pneumonia. Triple therapy vancomycin + colistin + meropenem was administered for 25 days, adding fluconazole 400 mg/24 hours until day 36, when sepsis was considered cured and the patient was discharged on day 42. Conclusions: The case has several distinctive features: (1) the discrepancy between the severity of symptoms and mild coronary lesions probably explained by the fact that the infarct vessel was LAD, which recovered patency after adjunctive treatment with consecutive reperfusion syndrome, (2) lack of favorable effect of angioplasty, (3) hemodynamic recovery under IABP with improvement of global and segmental LV dysfunction, (4) presence of Mendelson’s syndrome and subsequent severe sespsis, (5) the need for prolonged mechanical ventilation – 28 days, (6) complexity of intensive care, focusing on the enteral nutrition via nasogastric tube, (7) prolonged antibiotic therapy with nephrotoxic effect that led to acute kinley injury, resolved prior to discharge.

ISSN – online: 2734 – 6382
ISSN-L 1220-658X
ISSN – print: 1220-658X
The Romanian Journal of Cardiology is indexed by:
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CODE: 379
CME Credits: 10 (Romanian College of Physicians)