Initial cardiac rhythm recorded in ambulance at 06:57.

Asystole is commonly the end-stage rhythm that follows prolonged VF or PEA, and for this reason the prognosis is generally much worse.



Echocardiogram was then performed to look for any cardiac motion.

In the setting of cardiac arrest, echocardiography can improve the outcome of cardiopulmonary resuscitation by

  1. 1.identifying organized cardiac contractility to help the clinician distinguish among asystole, pulseless electrical activity (PEA), and pseudo-PEA;

  2. 2.determining a cardiac cause of the cardiac arrest; and 

  3. 3.guiding lifesaving procedures at the bedside.

In a patient with no ventricular cardiac contraction and an asystolic electrocardiogram, the survival rate is low despite aggressive ACLS resuscitation.

True PEA is defined as the clinical absence of ventricular contraction despite the presence of electrical activity, whereas pseudo-PEA is defined as the presence of ventricular contractility visualized on cardiac ultrasound in a patient without palpable pulses.

Therefore, making the diagnosis of pseudo-PEA can be of diagnostic and prognostic importance. Patients with pseudo-PEA have some observable, although minimal, cardiac output and have a higher survival rate, in part because there are often identifiable and treatable causes of

their arrest.


Resuscitation was then continued following the ACLS protocol.

Finally patient had ROSC at 07:19.

Below was the ECG performed at 07:23.

This is the PLAX parasternal long axis view of the heart. The cardiac contractility was normal. Left ventricle was small and under filled. No pericardial effusion or mass lesion (tumor, clot) was detected. Right ventricle was not dilated in this view.

With the presence of cardiac kinetic motion, the diagnosis of Pseudo-PEA was made.

?Myocardial Infarction  ?Intracranial Hemorrhage


An Echocardiogram was performed.


A CT Brain was performed afterwards.

This the PLAX parasternal long axis view of the heart after ROSC. No RWMA regional wall motion abnormalities was reviewed.

This is the PSAX parasternal short axis view of the heart after ROSC. No RWMA regional wall motion abnormalities was reviewed.

Neurosurgery was consulted.

In view of poor grade SAH, they decided no neurosurgical intervention in this case.

Patient was then transferred to ICU for further care.


At the end......

Patient was certified brain death at 13:30 on Day 3.




  1. BulletAlthough the patient was died.

  2. BulletHer loved ones could see her before she was certified death.

  3. BulletMoreover, her family was interviewed by transplant coordinator and agreed for organ donation.

  4. BulletLiver (L & R lobe) and Kidney (L & R) donation was arranged.

  5. BulletFour other lives have been saved.

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Diffuse SAH noted in bilateral cerebral hemisphere, most evident at the basal cisterns, floor of anterior cranial fossa, right sylvian fissure, the interhemispheric fissure, and left frontal region