An otherwise healthy 75-year-old man had a spontaneous collapse on a golf course, witnessed by other club members. He had no pulse and was not breathing and received cardiopulmonary resuscitation (CPR) from a bystander. After 15 minutes of CPR, a public automated external defibrillator (AED) was appropriately deployed, and he received one shock, following which he appeared to regain some consciousness.
Due to the rural location, the fastest prehospital transport to the scene was by air ambulance. A crew of two Critical Care Paramedics (CCPs) arrived to find the patient placed in the recovery position, spontaneously ventilating, with a palpable pulse, adequate blood pressure, normal oxygen saturation readings, and normal blood glucose. A 12-lead ECG showed no acute abnormalities.
The patient had a reduced Glasgow Coma Scale (GCS) and a unilateral fixed, dilated pupil. He exhibited trismus and occasional decorticate posturing. History from the patient's wife (via telephone) was that earlier in the morning he had slipped on some ice and fallen over, hitting his head, but had decided that he was well enough to play golf. Raised intracranial pressure was considered a possibility due to these signs. The patient was given high flow oxygen via a nonrebreathing mask and the airway was managed to good effect using basic manual techniques and a nasal pharyngeal airway.
Determining the aetiology of cardiac arrest in the prehospital environment can be difficult, and some of the differential diagnoses in this case included traumatic brain injury, acute myocardial infarction, or cerebrovascular accident. The CCPs made a decision to convey the patient to a Major Trauma Centre that had neurosurgical and cardiology specialist expertise, rather than the nearest hospital. When he arrived at the Emergency Department, he was anaesthetised and underwent rapid sequence induction. A head CT was performed, and this was reported as normal. He then proceeded to undergo coronary angiography, which demonstrated an occlusion of two coronary arteries. He underwent percutaneous coronary intervention (PCI) via the right radial artery, with angioplasty and stenting of the right coronary artery, left main stem, and proximal left anterior descending coronary artery.
During his inpatient stay, he informed medical staff that his left pupil has been permanently dilated since he was a boy, following a traumatic ocular injury whilst playing football (shown in Figure 1).