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In patients with multiple co-morbidities, identifying the culprit etiology of cardiac arrest can be challenging. We present a patient who suffered cardiac arrest and was found to have Aortic dissection (AD), pulmonary embolism, extensive thrombosis, and shock, complicating the treatment plan. A 63-year-old man collapsed at work and was found to be pulseless with ventricular fibrillation rhythm, with down time over 30 minutes. He had ischemic cardiomyopathy with 3 vessel disease and chronic total occlusion of left circumflex artery (figure 1). His post-arrest blood pressure was 199/100, heart rate 125 in atrial fibrillation, and he required mechanical ventilation. A computed tomography (CT) of the chest showed DeBakey type IIIB AD from the origin of the left subclavian to the abdominal aorta distal to the renal arteries. Intravenous esmolol and amiodarone were started but the patient developed hypotension requiring vasopressors. Transesophageal echocardiogram demonstrated depressed ejection fraction of 10% and a mobile thrombus in the right atrium extending from the inferior vena cava (IVC). The patient was deemed a poor surgical candidate. Given the IVC thrombus, a CT angiography of the chest was obtained, showing bilateral pulmonary emboli. Decision was made to start therapeutic anticoagulation despite AD. A magnetic resonance imaging of his brain showed bilateral acute infarcts complicating the decision to pursue cardiac catheterization and possible triple antithrombotic therapy. A trial of guideline directed medical therapy with carvedilol was initiated however the patient developed pulmonary edema and shock with predominant suspicion of being cardiogenic. There was poor improvement with inotropes and vasopressors. After multidisciplinary team discussion, mechanical circulatory support (MCS), including extracorporeal membrane oxygenation, was deemed futile due to prolonged down time, and challenging cannulation with extensive AD. The patient's family elected to withdraw care and the patient expired 10 days post-arrest. Use of MCS can be problematic with extensive AD due to challenges with cannulation. Further, there is paucity of evidence on anticoagulation in AD given risk of propagation of the dissection plane, albeit in our patient it was necessary. Multidisciplinary team approach can prioritize such interventions (figure 2). [ABSTRACT FROM AUTHOR]

KAREN ZEY @zippyzey At sixty, I joined Twitter as an emergent writer. My early efforts were couched in humor, but my #cnftweets soon shifted to more nuanced observations of both self and others - an ongoing effort to seek understanding and contentment at this stage of life. The Tiny Truths micro-essay seemed a good fit for my twinges of aging angst. [Extracted from the article]