History of presentation
A 60-years-old man with a previous history of persistent atrial
fibrillation (AF) treated with oral amiodarone was admitted for an
elective electrical cardioversion. A 200 J shock, under sedation with
propofol and midazolam, was ineffective and the decision was made to
administer a 300 mg bolus of intravenous amiodarone. Immediately after,
the patient presented an extensive skin rash associated with pruritus
that was shortly followed by cardiac arrest secondary to pulseless
electrical activity. Advanced cardiopulmonary resuscitation (CPR) was
started but the patient persisted in cardiac arrest. ST-segment
elevation was observed on the monitor so the patient was transferred to
the cathlab for emergent coronary angiography. A left main coronary
artery spasm was observed (figure 1) and complete reversal of spasm was
achieved after 5 bolus of intracoronary nitroglycerin. After 19 minutes
of advanced CPR with administration of 8 mg of adrenaline, 200 mg of
hydrocortisone and 5 mg of dexchlorpheniramine recovery of spontaneous
circulation was achieved. Echocardiography revealed biventricular severe
dysfunction (video 1). The patient remained in refractory shock despite
of high doses of vasoactive drugs so VA-ECMO and intra-aortic balloon
pump (IABP) were implanted.