PULSELESS ELECTRICAL ACTIVITY OR SILENT ELECTRICAL ACTIVITY?

CASE HISTORY:
70 YEAR OLD PATIENT WITH NO PREVIOUS MEDICAL ILLNESS IS ADMITTED TO THE ACCIDENT AND EMERGENCY DEPARTMENT WITH CHEST DISCOMFORT.  HIS PULSE RATE IS 64/MT, BP 90/50 MMHG AND ECG SHOWED ST SEGMENT ELEVATION.  A DIAGNOSIS OF ACUTE MI IS ESTABLISHED AND PATIENT WAS SHIFTED TO ICU FOR THROMBOLYTIC THERAPY. PATIENT IS CONSCIOUS BUT SEDATED DUE TO THE EFFECT OF MORPHINE AND OBEYING COMMANDS, CHEST ON AUSCULTATION REVEALED B/L FINE BASAL CREPS. OXYGEN ON FLOW 8L/MT BY FACE MASK. THE ECG SHOWED

AFTER ABOUT 20 MINUTES THE ICU STAFF NOTICED A FALL IN SPO2 AND PATIENT IS UNRESPONSIVE. CODE BLUE ALERT GIVEN. THE MONITOR SHOWED COMPLEXES SIMILAR TO THE PREVIOUS ECG AND NIBP SHOWED 80/60 MMHG WHICH WAS SET AUTOMATIC AT 3 MINUTES INTERVAL. PATIENT WAS GASPING AND THE ANAESTHETIST IMMEDIATELY INTUBATED THE PATIENT AND CPCR CONTINUED AS PER ACLS PROTOCOLS BUT COULD NOT BE REVIVED



PATIENT WENT INTO PEA IMMEDIATELY FOLLOWING LAST BP MEASUREMENT AND WAS IN CARDIORESPIRATORY ARREST FOR FOR MORE THAN TWO MINUTES. SINCE FRC IS ENRICHED WITH INITIAL HIGH CONCENTRATION OF OXYGEN, FALL IN OXYGEN SATURATION WAS SLOW AND THE MONITOR SHOWED NOISY SIGNAL WITH LOW AMPLITUDE PLETHISMO WAVES AND HEART RATE PICKED UP FROM  ECG, AS IT IS SET. ABSENT PULSE WAS UN NOTICED.



PEA CAN FOLLOW A/C MI BUT MAY BE UNRECOGNISED. SINCE MOST PEAs CAN BE SUCCESSFULLY TREATED WITH EFFECTIVE CPCR AND DRUGS,  ESPECIALLY IN YOUNG PATIENTS, CAREFUL AND CLOSE MONITORING OF POST MI PATIENTS IN ICU IS RECOMMENDED