A 55-year-old female was at home sitting at a table when her family noted that she suddenly lost consciousness. Paramedics were called and found her unresponsive with agonal respirations. Her blood glucose was measured at 109 mg/dL, intubation was attempted but was not successful, and rescue breathing by bag-valve-mask was performed as she was transported to the hospital.
On arrival in the emergency department, the patient was unresponsive and making sonorous breath sounds. Her heart rate was 138 beats per minute, respirations 22 breaths per minute, blood pressure 154/103 mmHg, and oxygen saturation 96% on 100% O2. Unable to maintain her airway as a consequence of her mental status and believed to be in need of emergent CT imaging of her brain upon arrival, she was intubated. No evidence of head or body trauma was noted, and pupils were 4 mm bilaterally and equal but not reactive. Her Glasgow Coma Score was 9 (E4, V1, M4). The rest of her physical exam was unremarkable except for a healing incision over the left great toe.
Past medical history obtained from her family was significant for hypertension, and her current medications included enalapril, amlodipine, and metoprolol. They also noted that she had undergone a left foot surgery 3 weeks prior to her presentation. They denied any history of tobacco, alcohol, or illicit drug use.
The patient was rapidly intubated and a stroke code called. At the same time, an ECG was obtained and revealed evidence of an inferolateral ST-segment elevation myocardial infarction (STEMI) (Figure 1). Although resulting after disposition, her initial laboratories revealed a pH of 7.26 and a lactate of 7.1 mmol/L. Serum chemistries demonstrated a sodium of 137 mmol/L, potassium of 3.4 mEq/L, chloride of 99 mEq/L, bicarbonate of 25 mEq/L, glucose of 234 mg/dL, creatinine of 0.9 mg/dL, and calcium of 9.2 mg/dL. The patient's white blood cell count was 15.6x103/uL, hemoglobin 14.2 g/dL, platelet count 298? ?103/uL, prothrombin time 10.6 s (INR of 0.9), and partial thromboplastin time 24.3 s. Her cardiac enzymes revealed a CKMB fraction of 3.4 units/L and a troponin I of 0.16 ng/mL (ref range 0.00 to 0.04).
Unstable and now with a suspected acute ST-elevation myocardial infarction, Cardiology was consulted and she was taken directly to the cardiac catheterization laboratory for revascularization prior to obtaining a head computer tomography (CT) scan. During the procedure, the patient received 2,500 units of heparin intraarterially but was not treated with any additional antiplatelet or anticoagulant therapy. The cardiac catheterization demonstrated normal coronary arteries with hypokinesis of the left ventricle.
Then, approximately 3 h after her arrival at the hospital, a noncontrast head CT was obtained that demonstrated a subarachnoid hemorrhage in the cisternal spaces around the cerebellum, in the prepontine and medullary cisterns and perimesencephalic and interpeduncular cisterns. This was associated with bilateral acute subdural hematomas, intraventricular hemorrhage, tonsillar and supratentorial herniation, and obstructive hydrocephalus (Figure 2). The patient was then transferred to the cardiac intensive care unit where Neurosurgery and Neurology were consulted and determined that she was clinically brain dead. With family involvement, assisted ventilation and vasopressor support was withdrawn and the patient expired on her fourth hospital day.