Precordial steering wheel: a fortunate accident.
BACKGROUND
Myocardial ischemia has been associated with motor vehicle collisions (MVCs). However, we were unable to find reported cases of ST-segment elevation myocardial infarction (STEMI) leading to ventricular tachyarrhythmia and subsequent MVC. In such patients, decisions regarding antiplatelet and antithrombotic therapy need to balance the risk of ongoing myocardial ischemia and hemorrhage.


OBJECTIVE
To describe a case of STEMI and ventricular fibrillation (VF) associated with a head-on MVC, and to describe the management decisions involved in the care of such a patient.


METHODS
A 47-year-old man presented to the Emergency Department after a single-car head-on collision with a wall at high speed. He had a facial degloving injury as well as right-sided flail chest. An electrocardiogram demonstrated ST-segment elevation in the inferior and anterior leads. Due to the patient's significant traumatic injuries, he underwent a rapid trauma evaluation and was transferred for emergent cardiac catheterization, which demonstrated evidence of plaque rupture in the right coronary artery (RCA). Flow distal to the lesion was preserved, so stent implantation was initially deferred out of concern for hemorrhage secondary to the aggressive antiplatelet and antithrombotic regimen requisite with stent implantation. The patient then went into VF in the cardiac catheterization laboratory, and repeat angiography demonstrated an occluded RCA, and the patient underwent successful stent implantation.


CONCLUSIONS
The management of STEMI in the setting of trauma is complex. Pharmacologic agents used in STEMI increase the risk of bleeding, and management must balance the risk of prolonged ischemia with the risk of hemorrhage.
Pride
Yuri B
YB
Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts 02215, USA.
Frost
Elizabeth J
EJ
Anderson
Philip D
PD
Cutlip
Donald E
DE
D000063:Accidents, Traffic; D004562:Electrocardiography; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000150:complications*; D017202:Myocardial Ischemia / Q000209:etiology* / Q000628:therapy; D015607:Stents; D014693:Ventricular Fibrillation / Q000209:etiology* / Q000628:therapy