Obtain a 12-lead ECG with return of spontaneous circulation (ROSC)

Here are some interesting ECGs from a cardiac arrest I worked recently. The arrest was witnessed but there was no CPR prior to EMS arrival. So, we performed 2-minutes of CPR prior to the first shock.


Here’s the 12 lead ECG we captured after ROSC:


As a side note, what is the cardiac rhythm? If you know, leave a comment.

Capturing a 12 lead ECG is particularly important if you need to justify transporting a cardiac arrest patient with ROSC to an interventional facility (PCI-hospital).

The American Heart Association published a policy statement on out-of-hospital cardiac arrest in January 2010.

Regional systems of care for out-of-hospital cardiac arrest: A policy statement from the American Heart Association. Circulation. 2010 Feb 9;121(5):709-29. Epub 2010 Jan 14

This part is particularly relevant to our discussion:

“Up to 71% of patients with cardiac arrest have coronary artery disease, and nearly half have an acute coronary occlusion. There is a high incidence (97%) of coronary artery disease in patients resuscitated from OOHCA who undergo immediate angiography and a 50% incidence of acute coronary occlusion. However, the absence of ST elevation on a surface 12-lead electrocardiogram after resuscitation of circulation from cardiac arrest is not strongly predictive of the absence of coronary occlusion on acute angiography. A case series of patients with unsuccessful field resuscitation suggested that in such patients, VF is more likely to be due to coronary disease than is asystole or pulseless electric activity…these studies suggest that patients who are resuscitated from out-of-hospital VF have a high likelihood of having an acute coronary occlusion.

“The feasibility and efficacy of primary PCI in patients who survive cardiac arrest with STEMI have been well established. The combination of mild therapeutic hypothermia with primary PCI is feasible, may not delay time to start of primary PCI in well-organized hospitals, and is associated with a good 6-month survival rate and neurological outcome…

“Patients resuscitated from OOHCA with STEMI should undergo immediate angiography and receive PCI as needed. Immediate coronary angiography is reasonable for patients resuscitated from VF and may be considered in patients resuscitated from other initial rhythms who do not have a clear noncardiac cause of cardiac arrest…Because emergent coronary angiography is not widely available, patients resuscitated from out-of-hospital VF or from OOHCA with STEMI should be transported as soon as it is feasible to a facility that is capable of performing these procedures. Field providers treating such patients should bypass referral hospitals and go directly to a cardiac resuscitation receiving hospital so that these patients can receive angiography within 90 minutes…”

4 Comments

  • Bob Jester says:

    Is teh rhythm a wandering atrial pacemaker?

  • Tom B says:

    I don’t know, Bob! I can’t decide. At first I thought 2AVB Type I and now I’m leaning toward atrial bigeminy, at least in the beginning of the 12 lead! Tom

  • MedicDan says:

    I would say 1st degree with atrial bigeminy. 

  • greg k says:

    first  are  there   pulses   ,  if  pulses   we  have   inferolateral  wall  which  prompts   posterior  and  rvi  rule  outs   2nd   bifasicular   block   right  axis   pathological  left  posterior   blockage  all  in  all  you   dont  want  this   pattern  as  your  own  cardiac  status   outlook   not  good!!!!!!~

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