Coronary Spasm in Septic Shock

Report:

Top strip:

Sinus tachycardia 117/min

Strips 2-5:

Sinus rhythm 53/min (2nd strip) – 61/min (bottom)

1o and progressive 2o AV block

Junctional escape beats

Markes ST segment elevation consistent with acute infarction or ischæmia

Comment:

In this critical care setting there is great likelihood the patient is heading into cardiac arrest in asystole or VF or EMD; this is no time for obtaining 12-lead ECGs. He indeed arrested in electro-mechanical dissociation (EMD, now called PEA – pulseless electrical activity) and received CPR for a minute and a half, along with some adrenaline and bicarbonate; the ventilation became manual and fast (one cannot rely entirely on bicarbonate to control the pH).

Fig 105a shows return of reasonably formed broad complexes through the CPR artefact (also looking like broad complexes, but “marching through” them).

Fig 105b shows return to sinus tachycardia with almost complete resultion of the ST segment elevation. The BP was over 130 mmHg systolic.

The rapid reversibility of ST segment elevation implies spasm, especially if it recurrs (it did here two more times). In susceptible individuals hypotension provokes it. Nitroglycerin or nifedipine may in fact be tried in order to prevent it, but only if the systemic BP can be maintained by, e.g., noradrenaline, at the same time. The benefit of coronary vasodilators in this situation remains (to me, at least) unknown and I do not use them as I would in ordinary Prinzmetal angina.