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Left ventricular thrombus (LVT) is a well-known complication of myocardial infarction (MI) leading to significant morbidity and mortality. LVT can also lead to systemic thromboembolic events causing threatening limb ischemia. We report a rare case of critical bilateral limb ischemia that resulted from peripheral embolization of LVT post MI, which was managed successfully by emergent surgical intervention and anticoagulation. A 74-year-old male with a medical history of hypertension, diabetes, hyperlipidemia and coronary artery disease status post stenting of the left anterior descending and left circumflex arteries presented to the emergency department with typical chest pain and progressive shortness of breath. Cardiac troponin levels on admission were 35 ng/mL of blood. The patient subsequently underwent emergent cardiac catheterization which revealed significant triple vessel disease, and was referred for coronary artery bypass grafting (CABG) surgery. Transthoracic and transesophageal echocardiograms revealed the presence of an apical aneurysm with chronic organized mobile thrombus at the apex. Post CABG, the patient complained of excruciating right leg pain. Computed tomography (CT) angiogram of the abdominal aorta and lower extremities revealed a large embolus at the aortic bifurcation occluding the right and nearly occluding the left common iliac arteries and thrombus in the right popliteal artery. He underwent emergent vascular surgery with resolution of his symptoms and remained without further complications. The incidence of LVT remains high in post-MI patients, and complications of LVT are known to include thromboembolic events. Peripheral embolization of acute or chronic LVT leading to bilateral distal embolization and critical limb ischemia remains a rare occurrence. This case report aims to aid clinicians to recognize and promptly manage LVT and related arterial thromboembolic events with anticoagulation and emergent surgical intervention if limb ischemia develops.

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Background: Little is known about cardiac arrests (CA) in the Emergency Department (ED). The objective of this study was to determine the characteristics of ED CA’s. Methods: Included were 60,852 adult, in-patient CA index events in the National Registry of Cardiopulmonary Resuscitation. Multiple regression analysis compared ED CA with those occurring in the ICU, telemetry, or general floors. Subgroup analysis examined traumatic vs. non-traumatic ED CA and ED CA occurring after a successful pre-hospital resuscitation (recurrent) vs. primary ED CA. Results: In multivariate analysis, ED location significantly predicted improved survival to discharge (OR 0.74, 95% CI[0.67–0.82], p<0.0001). Patients with CA occurring in the ED had better Cerebral Performance Category scores (ED 1.59, ICU 1.73, Tele 1.96, Floor 1.69, p<0.0001), shorter mean post-event length of stays (ED 8.6, ICU 17.5, Tele 16.5, Floor 14.2 days, p<0.0001) and were less likely to be declared DNR (ED 23.0%, ICU 31.7%, Tele 28.8%, Floor 31.8%, p<0.0001) than CA in other locations. Secondary analysis showed that ED patients with recurrent CA were less likely to survive to discharge (10.1% vs. 24.6%, p<0.0001) and were more likely to be declared DNR (27.9% vs. 22.2%, p<0.0006.) than primary ED CA. Mean length of stay for survivors in both groups was similar (8.85 vs. 8.54 days, p=ns). Major traumatic injury preceded 6.3% of all ED CA. Patients whose ED CA was related to traumatic injury were younger (46.2 vs. 65.0 years, p<0.001), more likely to be male (78.2% vs. 58.1, p<0.0001), less likely to have the CA caused by an arrythmia (23.6% vs. 32.5%, p<0.0008), and more likely to have the CA preceded by hypotension or shock (41.6% vs. 29.0%, p<0.0001) than ED patients whose CA was not due to traumatic injury. ED trauma CA patients had a significantly lower survival to discharge rate than ED patients whose CA was not due to trauma (7.5% vs. 23.8%, p<0.0001). Conclusions: ED CA patients are a unique population and have better survival and neurologic outcomes compared to patients in other hospital locations. Primary ED CA patients have a better chance of survival to discharge than those who re-arrest following a successful pre-hospital resuscitation. Traumatic ED CA patients have worse outcomes than non-traumatic CA.

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