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Case Study
By Cardiothoracics Society
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Case Study: Collapse on the Pitch

You are the team doctor for a premier league football club. During a match one of your players, an athletic 23-year-old man with no previous health problems other than a strong family history of type-2-diabetes, falls to the ground off the ball. The referee stops play and you rush over to find your player unconscious [Q1 what is your immediate management for this patient.] [Q2 list 5 differential diagnoses for sudden collapse]. Your initial assessment shows the patient has no pulse and you suspect cardiac arrest. You are able to remove him from the field whilst performing continuous CPR. A biphasic AED (defibrillator) is attached and records ventricular fibrillation. IV access is also gained. Fifteen shocks are given in the ambulance in combination with continuous CPR before a pulse finally returns. The patient regains some consciousness but is largely unresponsive. Collateral history from his family reports that he was feeling unwell this morning and vomited 3 times before breakfast, but chose not to inform the medical staff as he did not want to miss the match. An ECG was recorded in the ambulance (see below). [Q3 describe the changes the ECG shows. Q4 what is the most likely diagnosis and what further investigations could you do to confirm this?] The patient is given high flow oxygen and suitable medication [Q5 What medication would be appropriate for this patient?]. Blood samples taken from the patient were tested for FBC, U&E, glucose, lipids and cardiac enzymes [Q6 Explain the reasons for performing each of these tests]. It is decided the patient is suitable for angioplasty and is taken immediately to the cardiac catheterization lab on arrival to hospital [Q7 In a media statement you are asked to describe what angioplasty is. Explain the process of angioplasty to a suitable level]. An alternative to angioplasty (where subcutaneous coronary intervention is not available) is thrombolysis. This should be given as soon as possible (minutes mean muscle), once contraindications are ruled out [Q8 One of the most important contraindications to thrombolysis is aortic dissection. What features of a history would you expect or what investigations could you do to rule out aortic dissection?]. Look ahead for answers... For more cardiothoracic case studies and news of upcoming events including teaching and clinical opportunities sign up to the cardiothoracic newsletter by emailing heart2heart to cardiothoracicssociety@gmail .com, or catch Cardiothoracis on the new MedSoc Website ... http://bit.ly/cardiothoracics Enjoy!

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Case Study: Collapse on the Pitch

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 game also 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 attack Other 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 the precordial 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 due to occlusion of the left anterior descending coronary artery. Investigations to confirm include a blood test for cardiac biomarkers 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 (antiemetic with morphine), GTN spray sublingual 2 puffs (symptomatic relief) and Atenolol 5mg IV (reduce heart rate and increase ejection fraction, note CI in asthma). You may also consider Clopidogrel and ACE inhibitors. 6. Explain the reason for performing each of these blood tests FBC check for anaemia (blood loss, work on heart) and leukocytosis (common in MI). U&E potassium levels (electrolyte disturbances may cause arrhythmias, particularly potassium and magnesium), renal function via eGFR and hydration status. Glucose check for hypoglycaemia. Lipids cholesterol ratios useful in assessing MI risk Cardiac enzymes Cardiac Troponins and Creatine Kinase. Cardiac troponins T and I have high sensitivity and specificity for cardiac damage. 7. In a media statement you are asked to describe what angioplasty is. Explain the process of angioplasty to 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 a history would you expect? What investigations could you do to rule out aortic dissection? History sudden tearing chest pain usually radiating to the back (interscapular pain). Often hard to differentiate from MI on history alone. Investigations Blood pressure and pulse are classically uneven in each arm, or between the arms and legs. Chest xray 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 up to the cardiothoracic newsletter by emailing heart2heart to cardiothoracicssociety@gmail.com or visit our page on the new Medsoc Website http://bit.ly/cardiothoracics or the Cardiothoracics Facebook page.