P040: PERIOPERATIVE MYOCARDIAL INFARCTION IN TRAUMA
Nicholas Baltera, DO; Sripad Rao, MD; Daniel Perez, MD
University of Miami/Jackson Health System
Introduction: In patients presenting with a ST segment elevation myocardial infarction (STEMI), the ACC/AHA guidelines recommend a door-to-balloon time of <90 minutes for patients (Pt) who undergo primary PCI. When Pt’s present with emergent traumatic surgical needs, this timeline can get prolonged. Damage control surgery and rapid resuscitation are paramount. Knowing the type of MI and the effects of different anesthesia techniques could be valuable. Inferior wall MI’s (IWMI’s) are estimated to be 40% to 50% of all MI’s. IWMI’s have a better prognosis than others, with a mortality of 2% to 9%. About 50% of patients with IWMI have complicating factors that can lead to increased mortality though. These factors include RV involvement and AV block. The physiologic insult from general anesthesia could be detrimental to a failing right heart. Regional techniques and its implications in trauma should also be weighed.
Case Presentation: A 62 year old male motorcyclist hit by car with history of hypertension, diabetes, and CAD with PCI presented to Ryder Trauma Center with a traumatic amputation of the left lower leg. The Pt was initially hypotensive but responded well to 2 units of whole blood. After CT imaging, the Pt was brought to the OR for a left below the knee guillotine amputation. After attaching the monitors to the Pt, ST segment elevation in lead II was noticed. A formal 12 lead EKG was done which showed elevations in II, III, AVF. Trauma surgery team was made aware of the STEMI and importance of a damage control surgery. An interventional cardiology consult was obtained. We proceeded with regional anesthesia via left femoral and lateral popliteal sciatic nerve blocks. After formalization of the BKA, we transported the patient to cardiac catheterization suite for angiography which revealed total thrombotic occlusion of the right coronary artery. There he had an aspiration thrombectomy, angioplasty, and stent placement. The patient was placed on DAPT for the remainder of his hospital course. He was taken for multiple I&D’s and an AKA. All surgeries were done under regional anesthesia. After his AKA procedure, Pt again had an instent thrombosis of his RCA. He underwent additional thrombectomy and stent placement. After a month and a half he was discharged to acute rehab and eventually home.
Discussion: Damage control surgery and rapid resuscitation is paramount for trauma patients with perioperative MI’s with emergent surgical needs prior to proceeding with coronary revascularization. In patients with IWMI’s, IV fluids and vasopressors should be used to maintain preload. Avoidance of nitrates and beta blockers may also be necessary. The ability to proceed with regional techniques in order to avoid physiologic insult of general anesthesia could be valuable. There are unique considerations for regional anesthesia in trauma patients, their ability for consent and communication, the priority for rapid resuscitation, positioning limitations, coagulopathies, unknown medical history and baseline neurologic/nerve function, the risk of compartment syndrome and infection all need to be weighed.