Hanging causing severe reversible left ventricular dysfunction

Excerpt

Sir: Few reversible left ventricular dysfunction without coronary artery lesions has been reported. We present the first case of reversible cardiogenic shock following hanging. In June 2004 the prehospital emergency medical team provided care to a 43-year-old, previously healthy woman, who attempted suicide by hanging. At the scene she had Glasgow Coma Scale of 3, SpO₂ 70%, blood pressure 120/80 mmHg, and heart rate 110 beats/min. After intubation her blood pressure dropped to 80/40 mmHg despite volume therapy. On admission computed tomography of the head and cervical spine was normal, and chest radiography showed mildly pulmonary vascular congestion. Electrocardiogram, creatine kinase, and cardiac troponin I were normal. Over the next 12 h, despite resuscitation attempts, hemodynamic instability persisted and hypoxemia worsened. Repeated chest radiography was remarkable for pulmonary edema. Transthoracic echocardiography revealed poor left ventricular function (ejection fraction 33%) with global hypokinesis. A Swan-Ganz catheter showed a cardiac index of 1.9 l/min⁻¹ m⁻², pulmonary capillary wedge pressure 18 mmHg, and systemic vascular resistance index 2480 dyne·s/cm⁻⁵ m⁻². Therefore diuretics and dobutamine were started. Subsequently, marked improvement in the patient’s neurological, respiratory, and hemodynamic status was noted. On day 2 peak creatine kinase was 458 IU/l, cardiac troponin I was 6.2 ng/ml (Fig. 1), but electrocardiography was unchanged. After a period of stability dobutamine was progressively discontinued. The patient was extubated on day 6, but she experienced a cardiogenic pulmonary edema. Noninvasive positive-pressure ventilation was initiated for an additional 24 h, and diuretics and dobutamine immediately restarted. A cardiac catheterization performed on day 8 revealed completely normal epicardial arteries. Dobutamine was replaced by ramipril, and the patient’s subsequent clinical course was uncomplicated. A follow-up cardiac echo obtained 14 days after hospital admission was normal.

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