Resuscitation 94 (2015) e9
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Letter to the Editor Electrocardiographic findings of intracranial haemorrhage as a cause of out-of-hospital cardiac arrest Sir, Intracranial haemorrhage (ICH) including spontaneous subarachnoid haemorrhage (SAH) is the most common neurological disorder leading to pre-hospital cardiac arrest (CA).1 Although electrocardiogram (ECG) changes, thought to be neurogenically mediated, are well known in patients with SAH, there is no previous report of these changes as a cause of out-of-hospital CA (OHCA). The typical ECG changes, such as ST-segment elevation or depression and abnormal T wave morphologies, may mimic myocardial infarction or ischaemia, which are the most common cause of CA.2,3 Furthermore, ICH patients also have elevated troponin levels. These nonspecific findings can lead to misdiagnosis and incorrect therapeutic decisions in these CA patients, such as thrombolytic therapy and percutaneous coronary intervention.4 Therefore, greater knowledge of ECG changes in ICH as a cause of OHCA may help to accelerate the selection of appropriate therapies. During the 9-year period, 473 of the 736 OHCA patients achieved ROSC in our emergency department. A total of 194 patients without obvious cause of arrest underwent brain CT and 36 patients had Table 1 Electrocardiographic findings of the out-of-hospital cardiac arrest patients in this study with intracranial haemorrhage. Variables ST-segment
Elevation
Depression
Number of ST-segments Anterior leads V1 V2 V3 V4 aVR Lateral leads I aVL V5 V6 Inferior leads II III aVF T wave inversion Anterior leads Lateral leads Inferior leads
1.0 (1.0–2.0) 24 (66.7%) 8 (22.2%) 4 (11.1%) 3 (8.3%) 2 (5.6%) 19 (51.4%) 6 (16.7%) 3 (8.3%) 5 (13.9%) 3 (8.3%) 2 (5.6%) 4 (11.1%) 0 (0%) 4 (11.1%) 0 (0%) 20 (55.6%) 11 (30.6%) 16 (44.4%) 11 (30.6%)
5.0 (2.3–7.0) 32 (88.9%) 5 (13.9%) 14 (38.9%) 19 (52.8%) 28 (77.8%) 4 (11.1%) 29 (80.6%) 11 (30.6%) 8 (22.2%) 26 (72.2%) 22 (61.1%) 20 (55.6%) 14 (38.9%) 8 (22.2%) 12 (33.3%)
Values are expressed as mean ± standard deviation, median with interquartile range, or n (%).
http://dx.doi.org/10.1016/j.resuscitation.2015.06.019 0300-9572/© 2015 Elsevier Ireland Ltd. All rights reserved.
ICH, 27 had SAH and 9 had other types of ICH. Most patients had tachycardia (86.1%) and a QTc prolongation (52.8%). To the best of our knowledge, this is the first report to demonstrate analysis of ECG findings in ICH-induced OHCA patients. The ECG characteristics in patients with ICH after resuscitation from OHCA were as follows: (a) although ST-segment elevation was seen in 77.8% of patients, especially in the aVR (51.4%) and V1 (22.2%) leads, ST-segment elevation in two contiguous leads was rarely seen; (b) ST-segment depression was found in 97.1% of leads, predominantly in anterior (88.9%) and lateral (80.6%) leads; (c) T wave inversion was seen in 54.1%, frequently in lateral leads (44.4%) (Table 1). Although we cannot compare with control group, we believe that the observed ECG characteristics of ICH reported here, such as ST-segment elevation in the aVR or V1 lead, ST-segment depression in multiple leads, and T wave inversion in lateral leads, have potentially significant implications when considering the possibility of ICH in OHCA survivors. Conflict of interest statement No conflicts of interest to declare. References 1. Huang J, van Gelder JM. The probability of sudden death from rupture of intracranial aneurysms: a meta-analysis. Neurosurgery 2002;51:1101–7. 2. Sommargren CE. Electrocardiographic abnormalities in patients with subarachnoid hemorrhage. Am J Crit Care 2002;11:48–56. 3. Mitsuma W, Ito M, Kodama M, Takano H, Tomita M, Saito N, et al. Clinical and cardiac features of patients with subarachnoid haemorrhage presenting with outof-hospital cardiac arrest. Resuscitation 2011;82:1294–7. 4. Prout R, Nolan J. Out-of-hospital cardiac arrest: an indication for immediate computed tomography brain imaging? Resuscitation 2009;80:969–70.
Youn-Jung Kim Won Young Kim ∗ Department of Emergency Medicine, Ulsan University College of Medicine, Asan Medical Center, Seoul, Republic of Korea Gi-Byoung Nam Department of Internal Medicine, Ulsan University College of Medicine, Asan Medical Center, Seoul, Republic of Korea ∗ Corresponding author at: Department of Emergency Medicine, Ulsan University College of Medicine, Asan Medical Center, 86 Asanbyeongwon-gil, Songpa-gu, Seoul 138-736, Republic of Korea. E-mail address: [email protected] (W.Y. Kim)
26 June 2015
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Letter to the Editor Electrocardiographic findings of intracranial haemorrhage as a cause of out-of-hospital cardiac arrest Sir, Intracranial haemorrhage (ICH) including spontaneous subarachnoid haemorrhage (SAH) is the most common neurological disorder leading to pre-hospital cardiac arrest (CA).1 Although electrocardiogram (ECG) changes, thought to be neurogenically mediated, are well known in patients with SAH, there is no previous report of these changes as a cause of out-of-hospital CA (OHCA). The typical ECG changes, such as ST-segment elevation or depression and abnormal T wave morphologies, may mimic myocardial infarction or ischaemia, which are the most common cause of CA.2,3 Furthermore, ICH patients also have elevated troponin levels. These nonspecific findings can lead to misdiagnosis and incorrect therapeutic decisions in these CA patients, such as thrombolytic therapy and percutaneous coronary intervention.4 Therefore, greater knowledge of ECG changes in ICH as a cause of OHCA may help to accelerate the selection of appropriate therapies. During the 9-year period, 473 of the 736 OHCA patients achieved ROSC in our emergency department. A total of 194 patients without obvious cause of arrest underwent brain CT and 36 patients had Table 1 Electrocardiographic findings of the out-of-hospital cardiac arrest patients in this study with intracranial haemorrhage. Variables ST-segment
Elevation
Depression
Number of ST-segments Anterior leads V1 V2 V3 V4 aVR Lateral leads I aVL V5 V6 Inferior leads II III aVF T wave inversion Anterior leads Lateral leads Inferior leads
1.0 (1.0–2.0) 24 (66.7%) 8 (22.2%) 4 (11.1%) 3 (8.3%) 2 (5.6%) 19 (51.4%) 6 (16.7%) 3 (8.3%) 5 (13.9%) 3 (8.3%) 2 (5.6%) 4 (11.1%) 0 (0%) 4 (11.1%) 0 (0%) 20 (55.6%) 11 (30.6%) 16 (44.4%) 11 (30.6%)
5.0 (2.3–7.0) 32 (88.9%) 5 (13.9%) 14 (38.9%) 19 (52.8%) 28 (77.8%) 4 (11.1%) 29 (80.6%) 11 (30.6%) 8 (22.2%) 26 (72.2%) 22 (61.1%) 20 (55.6%) 14 (38.9%) 8 (22.2%) 12 (33.3%)
Values are expressed as mean ± standard deviation, median with interquartile range, or n (%).
http://dx.doi.org/10.1016/j.resuscitation.2015.06.019 0300-9572/© 2015 Elsevier Ireland Ltd. All rights reserved.
ICH, 27 had SAH and 9 had other types of ICH. Most patients had tachycardia (86.1%) and a QTc prolongation (52.8%). To the best of our knowledge, this is the first report to demonstrate analysis of ECG findings in ICH-induced OHCA patients. The ECG characteristics in patients with ICH after resuscitation from OHCA were as follows: (a) although ST-segment elevation was seen in 77.8% of patients, especially in the aVR (51.4%) and V1 (22.2%) leads, ST-segment elevation in two contiguous leads was rarely seen; (b) ST-segment depression was found in 97.1% of leads, predominantly in anterior (88.9%) and lateral (80.6%) leads; (c) T wave inversion was seen in 54.1%, frequently in lateral leads (44.4%) (Table 1). Although we cannot compare with control group, we believe that the observed ECG characteristics of ICH reported here, such as ST-segment elevation in the aVR or V1 lead, ST-segment depression in multiple leads, and T wave inversion in lateral leads, have potentially significant implications when considering the possibility of ICH in OHCA survivors. Conflict of interest statement No conflicts of interest to declare. References 1. Huang J, van Gelder JM. The probability of sudden death from rupture of intracranial aneurysms: a meta-analysis. Neurosurgery 2002;51:1101–7. 2. Sommargren CE. Electrocardiographic abnormalities in patients with subarachnoid hemorrhage. Am J Crit Care 2002;11:48–56. 3. Mitsuma W, Ito M, Kodama M, Takano H, Tomita M, Saito N, et al. Clinical and cardiac features of patients with subarachnoid haemorrhage presenting with outof-hospital cardiac arrest. Resuscitation 2011;82:1294–7. 4. Prout R, Nolan J. Out-of-hospital cardiac arrest: an indication for immediate computed tomography brain imaging? Resuscitation 2009;80:969–70.
Youn-Jung Kim Won Young Kim ∗ Department of Emergency Medicine, Ulsan University College of Medicine, Asan Medical Center, Seoul, Republic of Korea Gi-Byoung Nam Department of Internal Medicine, Ulsan University College of Medicine, Asan Medical Center, Seoul, Republic of Korea ∗ Corresponding author at: Department of Emergency Medicine, Ulsan University College of Medicine, Asan Medical Center, 86 Asanbyeongwon-gil, Songpa-gu, Seoul 138-736, Republic of Korea. E-mail address: [email protected] (W.Y. Kim)
26 June 2015
