Post-cardiac arrest inferior STEMI — FFICM MCQ

Correct answer: E — Urgent coronary angiography with PCI pathway activation

The correct answer is E, urgent coronary angiography with PCI pathway activation. This man has ST elevation in II, III and aVF with reciprocal anterior changes, a classic pattern of acute coronary occlusion (inferior STEMI), which is the most likely cause of his VF arrest. Current UK post-resuscitation care guidance states that immediate coronary angiography should be prioritised for patients with clear ST elevation on the ECG after ROSC, irrespective of consciousness level, because coma from a witnessed VF arrest is expected and does not predict a poor neurological outcome. Reperfusion should not be delayed by attempts at neuroprognostication, since myocardial salvage is time critical and early revascularisation improves haemodynamic stability and reduces re-arrest risk. Temperature control, ventilation and other post-arrest bundle elements are managed in parallel with, not instead of, the angiography pathway. Why the other options are wrong: C. Delay angiography until neurological recovery is proven: Neurological status at this early stage is confounded by sedation, hypoxic insult and the arrest itself, and waiting for recovery would fatally delay reperfusion of an occluding coronary lesion. D. Give 30 ml/kg ice-cold saline for temperature control: Rapid infusion of large-volume cold intravenous fluids to induce hypothermia is no longer recommended as it offers no outcome benefit and risks pulmonary oedema and rebound hypothermia complications. A. Perform CT brain before cardiology referral: CT brain is reserved for cases where a non-cardiac cause is suspected clinically (for example headache, seizure, or a non-shockable rhythm); here the ECG already gives a clear cardiac cause, so imaging must not delay the coronary pathway. B. Extubate to assess neurology before transfer: The patient is sedated with GCS 3 secondary to sedation, not necessarily brain injury; extubation is unsafe pre-angiography and neurological assessment is invalid while sedated. Key point: Clear ST elevation after ROSC mandates immediate coronary angiography regardless of coma or sedation, as neuroprognostication cannot be reliably performed at this stage and reperfusion is time critical.

Reference: Resuscitation Council UK, Post-resuscitation Care Guidelines (2025), https://www.resus.org.uk/professional-library/2025-resuscitation-guidelines/post-resuscitation-care-guidelines