You are dispatched to a local restaurant for 27-year-old male who is unconscious. En route to the scene, dispatch gives you an update that the patient is in cardiac arrest At the time of EMS arrival, the patient is found supine on the floor in cardiopulmonary arrest.
Effective chest compressions are being performed by a nurse who had been having dinner with her husband. The patient is a server at the restaurant. His co-workers report that the collapse was witnessed and the patient had been behaving "normally" prior to the event. They are unaware of any significant medical history. The cardiac monitor is attached.
Paramedics deliver a shock at 150 J.
The post-shock rhythm is disorganized. CPR is continued per AHA guidelines.
The airway is captured with a King LT-D and asynchronous ventilations are delivered at a rate of 10/min with a good ETCO2 waveform.
An 18 ga IV is established in the left antecubital space. 1 mg of epinephrine 1:10,000 is given IVP.
2 minutes later an organized heart rhythm is noted on the monitor.
Vital signs are assessed. RR: 0 HR: 130 BP: 118/68 The patient remains comatose and therapeutic hypothermia is initiated using iced saline.
What would your diagnosis be?
This 12-lead ECG shows an abnormality called Brugada syndrome.
This abnormality was first reported in 1992 by the Brugada brothers. In a series of case studies, they showed that ST-elevation in leads V1-V3 with a structurally normal heart was associated with an inherited form of sudden cardiac death.
The AHA/ACCF Scientific Statement on the Evaluation of Syncope (Circulation 2006; 113:316-327) describes the disorder this way:
"The Brugada syndrome is a heritable disorder of the cardiac sodium channel resulting in ST-elevation in the anterior precordial leads (i.e, V1 and V2) and susceptibility to polymorphic ventricular tachycardia. The distinctive ECG pattern is diagnostic, although the ECG is often dynamic...Patients with Brugada syndrome who present with syncope have a 2-year risk of sudden cardiac death of 30%; hence, implantable defibrillator therapy is recommended."
So what about sudden cardiac arrest with ROSC?
In this case the ECG was suspicious but not diagnostic.
Importantly, the patient's co-workers reported that he seemed "perfectly normal" prior to collapse. This wasn't a patient who had been feeling ill or experiencing chest discomfort.
Further testing revealed clean coronaries and a structurally normal heart.
Brugada syndrome was diagnosed in the EP lab and the patient received an ICD.
He was discharged from the hospital neurologically intact.