Occlusive Explosion

ABSTRACT

Clinical Information Patient Initials or Identifier Number A Relevant Clinical History and Physical Exam 47yr old man, suffered a blast injury at the workplace after an O2 tank exploded while he was transferring liquid gas into a tank for welding purposes. The impact has caused him to temporary loss of consciousness. Upon awakening, he had severe chest pain associated with shortness of breath. On examination, superficial partial thickness injury on the chest wall, and lungs reduced breath sound bi-basally, no murmur heard. BP106/77mmHg, HR100/min, SPO2 100% on HFM 15L/min. [Formula presented] [Formula presented] [Formula presented] Relevant Test Results Prior to Catheterization Serial ECGs were done and showed dynamic changes in the anterior leads Bedside echo before invasive coronary angiograms shows mild LVSD, normal valves, and no pericardial effusion [Formula presented] [Formula presented] Relevant Catheterization Findings: Right radial approach 6F system Opitorque catheter for diagnostic angiogram LMS smooth LAD ATO mid LAD, DG1 prox ATO LCx smooth RCA smooth Impression ATO to LAD and Diagonal 1 ( Dual ATO) [Formula presented] [Formula presented] [Formula presented] Interventional Management Procedural Step Right radial coronary angiogram via 6F system EBU 3.0 engaged with good support Sion blue wired into LAD, export catheter delivered, and aspirated red thrombus Pre-dilated with Sapphire 3 SC 2.5x15mm @ 6-10ATM Flow established in LAD, however, decided to interrogate DG1 as it shows ATO BMW wired into the DG1 and pre-dilated with Sapphire 3 SC 2.0x15mm Noted nonflow limiting dissection and decided to stent DG1 with 2.25x34mm@12ATM, dissection sealed and TIMI III flow established Stented mid LAD with 2.5x30mm @12ATM just before LAD/DG1 bifurcation, then stented proximal LAD with 2.5x 26mm@ 12ATM. Post-dilated LAD with 2.75x15mm@ 14-20ATM TIMI II-III flow IV Tirofiban has been given a loading dose due to a high thrombus burden and sluggish flow [Formula presented] [Formula presented] [Formula presented] Conclusion(s) Myocardial infarction is a rare complication of blunt chest trauma. This case demonstrates how blast shock waves result in the dissection of the coronary vessel leading to total occlusion of the two vessels. It also promotes red thrombus within the coronary vessels. Percutaneous coronary intervention is the most suitable way to treat this condition. Intravascular imaging such as IVUS or OCT would be beneficial to demonstrate the physiology behind this MI and would also be helpful in planning and optimizing the lesions. Unfortunately, intravascular imaging was not used for this patient to reduce procedural time as he was treated during the height of the COVID pandemic.Copyright © 2023