Slide 1: 50-year-old male has a witnessed cardiac arrest. CPR is performed with ROSC. A post-arrest EKG is obtained. What does the EKG show?

Slide 2: Let’s examine the EKG with a systematic approach. Rate. 90 beats per minute. Rhythm. Atrial fibrillation. Axis. 90 degrees. Intervals. Normal. Morphology. 2 mm STE aVR. Diffuse STDs. Cardiac arrest in the setting of STE in aVR + diffuse STDs suggests global ischemia. See post from 1/28/2021.

Slide 3: Given a post-arrest EKG showing diffuse ischemia without other apparent causes for cardiac arrest, the patient went for emergent cardiac catheterization (CODE STEMI). Cath films show non-obstructive coronaries. RCA, LAD, and LCx are labeled. The patient remains obtunded. What’s your next step?

Slide 4: Patient taken for urgent head CT. Diagnosis?

Slide 5: Subarachnoid hemorrhage. T-wave inversions can be seen during elevated intracranial pressure (ICP), as in this case with SAH, that mimic ischemia. CT with arrow pointing to subarachnoid cisterns with blood and arrow pointing to severe cerebral edema with loss of grey-white matter differentiation 2/2 increased ICP. Note – in obtunded post-arrest patients without STEMI criteria on ECG, strongly consider head CT prior to cath lab.

Slide 6: Cerebral T-waves. Look for: TWI greater than or equal to 5 mm in greater than or equal to 4 contiguous precordial leads. Other common ECG findings include T wave inversion, ST depression, QTc prolongation, Bradycardia (Cushing reflex), and arrhythmia. Thought to be due to catecholamine surge, resulting in myocardial supply-demand mismatch and possible cardiac edema. Note – the Cushing reflex is a triad of hypertension, bradycardia and irregular respirations.

References

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  • Yannopoulos D, Bartos JA, Aufderheide TP, Callaway CW, Deo R, Garcia S, Halperin HR, Kern KB, Kudenchuk PJ, Neumar RW, Raveendran G; American Heart Association Emergency Cardiovascular Care Committee. The Evolving Role of the Cardiac Catheterization Laboratory in the Management of Patients With Out-of-Hospital Cardiac Arrest: A Scientific Statement From the American Heart Association. Circulation. 2019 Mar 19;139(12):e530-e552. PMID 30760026.
  • Stone J, Mor-Avi V, Ardelt A, Lang RM. Frequency of Inverted Electrocardiographic T Waves (Cerebral T Waves) in Patients With Acute Strokes and Their Relation to Left Ventricular Wall Motion Abnormalities. Am J Cardiol. 2018 Jan 1;121(1):120-124. PMID 29197472.
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