Patient
67-year-old male, brought in by EMS
EMS Presentation
BIBA after witnessed cardiac arrest at home. Wife initiated CPR immediately. EMS arrived at 6 min, found patient pulseless with VFib rhythm on monitor. Defibrillated x3, ROSC achieved at 12 min post-arrest. Given aspirin 325 mg PO, heparin 4000 U IV en route. Transport time 14 min.
Primary Survey
Airway: intubated with 7.5 ETT (EMS, 22 cm at teeth), bilateral breath sounds confirmed.
Breathing: ventilator-assisted, SpO2 96% on FiO2 40%.
Circulation: BP 98/62 (on norepinephrine 0.05 mcg/kg/min), HR 102 irregular.
Disability: GCS 3T (sedated), pupils 3mm equal and reactive.
Exposure: exposed for exam, temperature 97.8 F (post-ROSC cooling).
EKG
Sinus tachycardia ~100 bpm. STEMI pattern: ST elevation 3mm in II, III, aVF with reciprocal depression in I, aVL. Suggests inferior wall MI, likely RCA occlusion.
Labs (stat)
Troponin I: 2.84 ng/mL (elevated, consistent with acute MI)
BNP: 485 pg/mL
CBC: WBC 14.2, Hgb 13.8, Plt 212
BMP: K 4.0, Cr 1.3 (baseline 1.1), lactate 4.2
Coag: INR 1.0, PTT 28
ABG (on vent): pH 7.32, pCO2 38, pO2 88, HCO3 19
Point-of-Care Ultrasound
Cardiac: reduced EF visually estimated 35-40%, inferior wall hypokinesis. No pericardial effusion. IVC dilated, non-collapsable.
Clinical Assessment
Witnessed VFib cardiac arrest → ROSC at 12 min. Inferior STEMI on EKG. Post-cardiogenic shock on single pressor. High-risk patient — needs emergent revascularization.
ED Course / Interventions
- Dual antiplatelet: aspirin + ticagrelor 180 mg load
- Anticoagulation: heparin infusion started (goal PTT 50-70)
- Pressor support: norepinephrine titrated to MAP >65
- Targeted temperature management initiated (33 C target)
- Cardiology paged STAT — cath lab activated
- Foley placed, UO monitoring started
Disposition
Emergent cardiac catheterization lab activation for primary PCI. Patient accompanied by ED physician + RN to cath lab. Handoff completed using I-PASS format. Estimated door-to-balloon time: 42 minutes.