Friday, January 18, 2013

ST-segment elevation myocardial infarction after drowning



ST-segment elevation myocardial infarction after drowning

Authors: Hesham Rashad Omar, Madhu Shree Gundavaram, Ehab El-Khabiry, Yaseen Ali, and Enrico Mario Camporesi
Journal: Internal and Emergency Medicine (Italian Society of Internal Medicine)

Very interesting case study.  The morbidity and mortality from drowning stems from the primary hypoxic injury and can been seen in the end organ damage of patients, the most worrisome and devastating of which is usually encephalopathy.  This case highlights the cardiovascular effects of hypoxia in a patient who we would otherwise not expect to see it in.  The paper tells of a 16 year old patient who was brought in after a drowning injury in which the initial ECG showed ST segment elevations consistent with inferior MI.  The patient was then taken to the cath lab, but cath was cancelled due to resolving elevations in a repeat ECG;  eventual troponins were positive.  Unfortunately the patient continued to decompensate from there on out until he was diagnosed as brain dead.  

As we all know, MI can be the inciting event for drowning injury, but in a patient this age we can assume that it was an indicator of end organ injury.  I would have like to have seen a post-mortem report to determine if there was any cardiac abnormalities, but all in all an interesting case.

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2 comments:

  1. Thanks for posting this. It's an interesting case that highlights one of the issues with ICDs; at what point does the cardiac damage become severe enough to place the cause of death as AMI as opposed to drowning?
    There are cases where the cause of death has been listed as heart attack when the precipitating factor was a struggle in the water that included "experiencing respiratory impairment from submersion/immersion in liquid.” Any idea how this case was classified? Care to speculate if that classification would have been different had he been 86 and not 16?

    Changing gears to treatment; would you advocate following AMI protocols (MONA) in a drowning case based on 12 lead EKG changes? Obviously O2 is warranted but what about the others?

    Thanks,

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    Replies
    1. Bob: Thank you for your questions, sorry for the delay, I just now found the feature that tells me people have replied. As for your first question (how was this case classified) I have sent an email to the authors to find out and will let you know if they reply. In terms of treatment, I would think whatever protocol your agency/hospital uses should be followed as long as the importance of oxygenation is kept in mind. The role of morphine has come into question with some evidence of increased mortality, I know I try and control pain primarily with nitro while providing fluids for the expected BP drop. In some arrest situations we tend to overlook airway, but obviously this needs to remain a priority. Thanks again.

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