A 65-year-old female was transported to the emergency department (ED) at approximately 2:00 AM following a witnessed cardiac arrest. According to the patient’s husband, she had been asleep in bed when she awoke suddenly, sat upright, and reached for her albuterol inhaler before “collapsing.” He found her to be pulseless and initiated cardiopulmonary resuscitation (CPR) while placing a call to emergency medical services (EMS). On EMS arrival, the patient was unresponsive and continued to receive CPR. She was intubated in the field using a size 7.0 endotracheal tube. Her initial rhythm was pulseless electrical activity (PEA), but she converted to normal sinus rhythm after receiving 1mg of epinephrine intravenously and 15 total minutes of CPR. No further history was available.\nPer her husband, her past medical history was notable for “thyroid problems.” Her only medications were an albuterol inhaler, recently prescribed by her primary physician, and a multivitamin. She had no known drug allergies. On social history, the patient was not known to drink alcohol, smoke cigarettes, or use other substances. A family medical history and review of systems could not be obtained due to the acuity of her condition.\nOn examination, the patient was an obese female, intubated, and unresponsive. Her temperature was 37.1 degrees Celsius, blood pressure was 97/65 millimeters Hg, heart rate was 75 beats per minute (bpm). Her body mass index was estimated at 32. She was initially receiving assisted ventilation by EMS, but on examination in the ED she was found to have a spontaneous respiratory rate of 12 breaths per minute with an oxygen saturation of 98% on 40% fraction of inspired oxygen. Her head was atraumatic and normocephalic. Her pupillary exam showed mid-dilated symmetric pupils with sluggish reactivity to light. There was no hemotympanium or Battle’s sign. She had no apparent facial droop. An oral endotracheal tube was in place, confirmed with radiography and audible bilateral breath sounds. She had a full, supple neck without palpable masses, but additional exam was limited by body habitus. On cardiopulmonary exam, her lungs were clear to auscultation bilaterally and her heart had a regular rate and rhythm with no murmurs, gallops, or rubs. The patient’s abdomen was soft and nondistended with normal bowel sounds. On neurologic exam, her Glascow Coma Scale was 3T. She had diffusely decreased muscle tone, and 1+ patellar and brachioradialis deep tendon reflexes. Her musculoskeletal exam was unremarkable for deformity, erythema, or edema. Skin exam did not show any rashes, wounds or other lesions.\nInitial electrocardiogram (ECG) () showed normal sinus rhythm at a rate of 70 bpm, normal axis, normal intervals and no pathologic t-wave inversions or ST-segment changes. A complete blood count and complete metabolic panel were done (). Additional laboratory tests, including thyroid studies, were unremarkable except for an elevated lactic acid of 6.9 millimoles/liter (L) (). A point-of-care echocardiogram was performed, which demonstrated grossly normal heart chamber sizes and systolic function with no pericardial effusion (). A point-of-care ultrasound of the abdomen and thorax was negative for any intra-abdominal free fluid. There was bilateral lung sliding present and no B lines. An anterior to posterior chest radiograph (CXR) is shown in .\nThe etiology of the patient’s cardiac arrest was unknown until a further diagnostic test was performed that revealed the diagnosis.
A 57-year-old male hypertensive Caucasian patient on medical treatment for 1.5 months for non-organic-related AF was hospitalized in the ICU because of high-ventricular response AF (170 per minute). Biphasic CV with 100J was performed on the patient under medical treatment, and sinus rhythm was maintained. The patient had high-ventricular response AF (160 per minute) again after 2 days, biphasic CV with 200J was conducted again, and sinus rhythm was maintained. An apnea test (AT) was performed on the same night because frequent apneas were observed during sedation, and his body mass index (BMI) was 40.9kg/m2. The results were as follows: apnea-hypopnea index (AHI) of 71 per hour, desaturation period of 28 minutes, and minimum peripheral oxygen saturation (SpO2) of 68 %. The patient was discharged with nocturnal BiPAP—expiratory positive airway pressure of 8cm H2O and inspiratory positive airway pressure of 14cm H2O—and medical treatment. The patient was in sinus rhythm at the 1-month follow-up; thus, medication doses were decreased, AT was performed under BiPAP at the 6-month follow-up, and the results were as follows: AHI of 1 per hour, desaturation period of 1 minute, and minimum SpO2 of 87 %. The patient did not have AF within these 6 months. At the 12th month, the patient decided to undergo gastric bypass surgery. Up to the time of surgery, nocturnal BiPAP and medical treatment were continued. Within 6 months after the medical surgery, the patient lost 40kg and only medical treatment was continued. In the AT conducted in the 18th month (via spontaneous breathing), results in the range of AHI of 5 per hour, apnea index of 1 per hour, and minimum SpO2 of 93 % were observed; hence, bisoprolol fumarate was ended (Fig. ).