Open Access Highly Accessed Case report

Pulseless electrical activity during electroconvulsive therapy: a case report

Arun Kalava1*, Allison Kalstein1, Sander Koyfman2, Simon Mardakh1, Joel M Yarmush1 and Joseph SchianodiCola1

Author Affiliations

1 Department of Anesthesiology, New York Methodist Hospital, 506, 6th street, Brooklyn, NY, 11215, USA

2 Department of Psychiatry, New York Methodist Hospital, 506, 6th street, Brooklyn, NY, 11215, USA

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BMC Anesthesiology 2012, 12:8  doi:10.1186/1471-2253-12-8

Published: 31 May 2012

Abstract

Background

Arrhythmias resulting in cardiac arrest during electroconvulsive therapy have been reported. Most reported cases of cardiac arrest had asystole as the initial rhythm. Pulseless electrical activity as an initial rhythm of cardiac arrest during electroconvulsive therapy has never been reported. Also, thromboembolism after inflation of pneumatic tourniquet during lower limb surgery has been reported but never following tourniquet inflation during an electroconvulsive therapy.

Case presentation

We report a case involving an 81- year- old female who presented to us for an electroconvulsive therapy for severe depression and developed pulseless electrical activity immediately after electroconvulsive therapy. She was successfully resuscitated and was later found to have bilateral pulmonary emboli with a complete occlusion of the right lower lobe pulmonary artery. The source of embolus was from her left lower extremity deep venous thrombus, which we believe, got dislodged intraoperatively after inflation of pneumatic tourniquet. Our patient not only survived the massive pulmonary embolus, but also showed significant improvement in her mental status compared to her pre-admission level at the time of discharge to a sub-acute rehabilitation centre.

Conclusion

We recommend that patients who are elderly and at high risk of thromboembolism should selectively undergo a preoperative doppler ultrasound for deep venous thrombosis. Also, selective application of tourniquet in the upper limb, to monitor for seizure activity, would reduce the incidence of pulmonary thrombo-embolism as embolic events are significantly less from deep venous thromboses of upper extremities when compared to lower extremities.

Keywords:
ECT; Pulseless electrical activity; Tourniquet; Pulmonary embolism