AN ACUTE MYOCARDIAL INFARCTION CAUSING A MOTOR VEHICLE ACCIDENT OR THE MOTOR VEHICLE ACCIDENT CAUSING AN ACUTE MYOCARDIAL INFARCTION: A CLINICAL DILEMMA

Abstract

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Acute myocardial infarction is seen in very few patients (0.5%) who are admitted post-motor vehicle accidents (MVAs) (1). It is, however, one of the common natural causes of incapacitation leading to MVA (2). We present a case of a male, who suffered a V-fib cardiac arrest post-MVA and was subsequently diagnosed with a 99 percent occlusion of the proximal left main coronary artery. CASE PRESENTATION: A 68-year old male known to have hypertension was brought to the ED after a head-on motor vehicle collision. EMS reported that the patient self-extricated from the vehicle, walked on the sidewalk, and fell unconscious afterward with V-fib arrest. The patient achieved ROSC after one round of CPR with cardioversion, and 1mg epinephrine. Due to low GCS, he was intubated and transferred to ICU. His labs were significant for elevated white blood cells and troponin of 0.14 (normal<0.03). EKG showed sinus rhythm with non-specific ST-T wave changes in Leads I, aVL, V5, and V6. CT chest showed non-displaced multiple ribs and sternal fractures with small retrosternal hematoma. TTE demonstrated a 25-30% ejection fraction and multiple wall motion abnormalities with apical ballooning. The patient was extubated after his respiratory status showed signs of improvement. Meanwhile, since the troponin levels continued to rise (0.14 < 1.93 < 3.62 < 6.89 < 7.02), heparin drip was started. Although the patient was finally alert and oriented, he had amnesia of the event. However, he denied having any chest pain, or anginal symptoms before the accident. Our differential diagnoses were cardiac injury from either accident or CPR, Takostubo cardiomyopathy, or myocardial infarction. His repeat EKG was different from the one on arrival and showed biphasic T-wave in V2 -V3 and symmetric T-wave inversion in V4-V6. On the second day of his hospital stay, cardiac catheterization was performed that showed 99% proximal LAD stenosis, leading to percutaneous coronary intervention. His status slowly improved and was discharged on a life vest with a follow up with a cardiologist. DISCUSSION: While myocardial injury post blunt trauma, associated with MVAs, are common, thrombotic occlusions are rare. Unlike our case, in a few of the reported cases of thrombotic occlusion, (3) (4) the patients were fairly young. The presentations of the case poised a clinical dilemma because we could not establish if MI caused the MVA or vice-versa. Also, coronary thrombosis was not the top differential diagnosis in this case given the trauma, CPR, rib fractures, and TTE findings. Regardless, a timely cardiac catheterization with revascularization was performed, and the patient recovered. CONCLUSIONS: Acute myocardial infarction should always be one of the differential diagnoses after cardiac injury associated with trauma as timely cardiac catheterization and revascularization can be life-saving. Reference #1: 1.Alkhouli M, Alqahtani F. Incidence and outcomes of acute myocardial infarction during motor vehicle accident related hospitalizations. The American journal of cardiology. 2019 Mar 1;123(5):725-8. Reference #2: 2. Antecol DH, Roberts WC. Sudden death behind the wheel from natural disease in drivers of four-wheeled motorized vehicles. The American journal of cardiology. 1990 Dec 1;66(19):1329-35. Reference #3: 3.Watt AH, Stephens MR. Myocardial infarction after blunt chest trauma incurred during rugby football that later required cardiac transplantation. Heart. 1986 Apr 1;55(4):408-10. 4.Calvo Orbe L, Garcia Gallego F, Sobrino N, Sotillo J, Lopez-Sendon JL, Oliver J, Coma I, Frutos A, Sobrino JA, Navarro JM. Acute myocardial infarction after blunt chest trauma in young people: need for prompt intervention. Catheterization and cardiovascular diagnosis. 1991 Nov;24(3):182-5. DISCLOSURES: No relevant relationships by Abhishek Kalidas Kulkarni, source=Web Response No relevant relationships by Odalys Lara-Garcia, source=Web Response No relevant relationships by Ruby Maini, source=Web Response No relevant relationships by Priyanka Parajuli, source=Web Response No relevant relationships by Manjari Regmi, source=Web Response No relevant relationships by Mohsin Salih, source=Web Response No relevant relationships by Nitin Tandan, source=Web Response