7/31/2019 Cardiothoracics Case Study 2

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You are the team doctor for apremier league football club.

During a match one of yourplayers, an athletic 23-year-oldman with no previous healthproblems other than a strongfamily history of type-2-diabetes,falls to the ground off the ball.The referee stops play and yourush over to find your playerunconscious [Q1 what is yourimmediate management for thispatient.] [Q2 list 5 differentialdiagnoses for sudden collapse].

Your initial assessment showsthe patient has no pulse and yoususpect cardiac arrest. You areable to remove him from thefield whilst performingcontinuous CPR. A biphasic AED(defibrillator) is attached andrecords ventricular fibrillation. IVaccess is also gained. Fifteenshocks are given in theambulance in combination withcontinuous CPR before a pulsefinally returns. The patient

regains some consciousness butis largely unresponsive. Collateralhistory from his family reportsthat he was feeling unwell this

morning and vomited 3 timesbefore breakfast, but chose

not to inform the medical staffas he did not want to miss thematch.

An ECG was recorded in theambulance (see below).

[Q3 describe the changes theECG shows. Q4 what is themost likely diagnosis and whatfurther investigations couldyou do to confirm this?]

The patient is given high flowoxygen and suitablemedication [Q5 Whatmedication would beappropriate for this patient?].Blood samples taken from thepatient were tested for FBC,U&E, glucose, lipids andcardiac enzymes [Q6 Explainthe reasons for performingeach of these tests].

It is decided the patient is

suitable for angioplasty and istaken immediately to thecardiac catheterization lab onarrival to hospital [Q7 In a

media statement you areasked to describe whatangioplasty is. Explain theprocess of angioplasty to asuitable level]. An alternativeto angioplasty (wheresubcutaneous coronaryintervention is not available)

is thrombolysis. This shouldbe given as soon as possible(minutes mean muscle), oncecontraindications are ruledout [Q8 One of the mostimportant contraindicationsto thrombolysis is aorticdissection. What features of ahistory would you expect orwhat investigations could youdo to rule out aorticdissection?].

Look ahead for answers...

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Case Study: Collapse on the Pitch

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Collapse on the Pitch: Answers

1. What is your immediate management for this patient?

Use the DRS ABC approach (in the notable case of Fabrice Muamba, a cardiologist watching in the stands at the gamealso came to assist the team and took charge of care).

2. List 5 differential diagnoses for sudden collapse.

Vasovagal syncope

Epilepsy

Cardiac arrest

Stroke

Panic attackOther differentials may include hypoglycaemia, choking, Stokes-Adams attacks, diving (wheeeey) and many others.

3. Describe the changes the ECG shows.

ST segment elevation in leads I, aVL and the precordial leads (V2-V6). Also a loss of R wave progression across theprecordial leads and some symmetrical T wave inversion (lead III and aVF).

4. What is the most likely diagnosis and what investigations could you do to confirm this?

The ECG shows changes of an anterolateral myocardial infarction (acute coronary syndrome). Note this is usually dueto occlusion of the left anterior descending coronary artery. Investigations to confirm include a blood test for cardiacbiomarkers troponin and creatine kinase.

5. What medication would be suitable for this patient?

Aspirin 300mg PO (has an antiplatelet effect), Morphine 5-10mg IV (pain relief), Metoclopramide 10mg IV (antiemeticwith morphine), GTN spray sublingual 2 puffs (symptomatic relief) and Atenolol 5mg IV (reduce heart rate and increaseejection fraction, note CI in asthma). You may also consider Clopidogrel and ACE inhibitors.

6. Explain the reason for performing each of these blood tests

FBCcheck for anaemia (blood loss, work on heart) and leukocytosis (common in MI).U&Epotassium levels (electrolyte disturbances may cause arrhythmias, particularly potassium and magnesium), renalfunction via eGFR and hydration status.Glucosecheck for hypoglycaemia.Lipidscholesterol ratios useful in assessing MI riskCardiac enzymesCardiac Troponins and Creatine Kinase. Cardiac troponins T and I have high sensitivity andspecificity for cardiac damage.

7. In a media statement you are asked to describe what angioplasty is. Explain the process of angioplastyto a suitable level.

For a detailed answer go to the Cardiothoracics page on the new Medsoc Website: http://bit.ly/cardiothoracics

8. One of the most important contraindications to thrombolysis is aortic dissection. What features of ahistory would you expect? What investigations could you do to rule out aortic dissection?

Historysudden tearing chest pain usually radiating to the back (interscapular pain). Often hard to differentiate fromMI on history alone.

InvestigationsBlood pressure and pulse are classically uneven in each arm, or between the arms and legs. Chest x-ray reveals chest widening or pleural effusion. No MI changes are seen on ECG.

For more cardiothoracic case studies and news of upcoming events including teaching and clinical opportunities sign upto the cardiothoracic newsletter by emailing heart2heart to cardiothoracicssociety@gmail.comor visit our page on the new

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Case Study: Collapse on the Pitch

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