Collapse, Ventricular Tachycardia, Cardioverted, Comatose on Arrival. OMI is a clinical diagnosis.

A middle-aged woman cried out, then collapsed.  She had bystander CPR.  First responders palpated a pulse.  Paramedics found her to be in Ventricular Tachycardia.  She underwent synchronized cardioversion.

On arrival, she had this ECG:

What do you think?

There is sinus rhythm. The ECG shows unequivocal ST Elevation in I and aVL, with reciprocal inferior ST Depression, and also STE in V3-V6.  There is unequivocal subepicardial (transmural) ischemia on this ECG.  This is probably a proximal LAD occlusion, right?

Not so fast!!

This patient dropped to the ground, and in spite of VT with a pulse (not VF without pulse), she remained comatose and was a GCS of 3.  This does not make sense.  If the patient had a pulse, there should have been brain perfusion and she should not be so deeply comatose.

I saw this patient (many years ago, before starting blogging in 2008) and thought, "this could be intracranial bleed with a pseudoSTEMI pattern."  

So we did a head CT before activating the cath lab and there was a huge spontaneous aneurysmal subarachnoid hemorrhage.

We must have done a bedside echo, but I don't remember what it showed (was there apical ballooning?)

Unfortunately, the patient went on to brain death.

Learning Point:

Patients who present deeply comatose after cardiac arrest do so because there is a brief (at least several minutes) period of no cardiac output and thus no perfusion of the brain.  If there was no such period of near zero cardiac output, then you should suspect an intracranial bleed, or perhaps basilar artery occlusion, as the etiology of the arrest and of the ECG findings.  

(I say "perhaps" for basilar artery occlusion because, although it may result in sudden deep coma, I am unaware of associated ECG findings)