65 year old male CC: Cardiac arrest on the tennis court

65 year old male collapses while playing tennis. The scene is less than 1 minute from the fire station.

On arrival, bystanders are providing rescue breaths but no chest compressions.

Medical history is unknown.

Initial rhythm:


First shock:


Return of spontaneous circulation (ROSC) noted.

Rhythm strip:

12 lead ECG:


The patient is still unconscious. LMA is placed and patient is ventilated 8/min. with 100% oxygen.

Vital signs:

  • RR: 0
  • Pulse: 82
  • NIBP: 112/82
  • SpO2: 100

What should happen next?

What is the patient's prognosis?

13 Comments

  • Brian T says:

    His 12 lead shows ST depression in v3-v6 concerning for myocardial ischemia. Most concerning here though is the r on t pvc. Perhaps this is what put him into VF in the first place. He should recieve 150mg Amiodarone over 10min and theraputic hypothermia should be initiated if available. I would also check a blood glucose and give him 2mg narcan due to his absent respiratory effort.

  • Christopher says:

    Running down my H's and T's I see two things. One, possible STD in V4-V5, and two, tall peaky T-waves, esp V3 where the T amplitude is greater than the R wave. As Brian noted, the R on T PVC is troublesome. But, I'm not as concerned about an OD due to the tennis action.Bolus and maintain an antiarrhythmic (amio/lido), repeat 12L (call STEMI if indicated), gather additional history on pt, guide ventilations with capnography, and consider possible Rx for hyperkalemia (however ROSC achieved, might wait on ED labs instead). If hypo protocols are in place, those go here as well.AHA would say that the prognosis is down at least 10-20% due to the lack of CPR for probably 2 minutes. It is promising that the pt converted after the first shock. However, I don't have enough experience yet to make a call on the prognosis.

  • SoCal Medic says:

    Consider your unknowns, sugar, drugs, history, H's and T's. Start two lines, maintain ventilation rate. Locally, not much we would do other than transport Code 3 to the hospital, unless the patient signs/symptoms were to change. Discussion would be had with the physician regarding the PVC and the possibility to administer a drip to prevent another PVC from placing the patient back into VFib. We do not have hypothermia protocols here locally. The conversion is nice considering CPR was not performed, but the potential for lack of circulation of blood flow for greater than a couple of minutes would play into his recovery process. The ST Depression in V3-V6 could be ischemic changes, but it could also be in my mind caused by the arrest and shock.

  • Jesse says:

    Theres a few things of note here, but not much I would really act on. Depression in anterior leads, but Im with chris on those being most likely due to some form of post cardiac arrest electrolyte imbalance. The T waves are indeed a mite peaky, but not to the extent I would consider hyperkalemia. T wave inversions in V1 and mildly late R/S transition, but I would view these as fairly beningn. As seems to be the general consensus, that R on T pvc is the most worring of the findings, and has the highest possibility of actually being related to this incident. Keeping another like that from terminating his now beautiful rhythm would be my highest, and really only, ecg indicated priority.

  • Brian T says:

    Just an addition to my original post: I also noticed the impressive T waves. They are not extremely concerning to me however given their height in relation to the QRS amplitude. In other words, in the setting of hight amplitude QRS complexes, I expect to see high amplitude t waves. This is most apparent in v3-v4. As far as prognosis goes: I think this guy is THE prime candidate for hypothermia. The fact that he was successfully defibrillated without prior CPR suggests that he was in the "electrical phase" of VF which lasts for approx 5 min. It is very possible then that permanant anoxic brain injury had not quite begun yet. I am curious as to why 2min CPR was not performed prior to and immediately after defib by the EMS providers. Any info on that?

  • Tom B says:

    Hi, guys!Sorry for the delay. I'm extremely busy between my regular duties, the launch of ePCR, the Captain's promotional process, and preparing my blog for the migration over to ems12lead.com.@Brian T – I'm not convinced that PVC isn't artifactual. I'm also not a huge fan of prehospital antiarrhythmics, although I certainly wouldn't criticize you for giving 150 mg amiodarone over 10 minutes post-arrest. I agree that this patient would have been a candidate for induced hypothermia, although even without it he did well. As for the glucose and narcan, the recent history of playing tennis makes me think that opioids aren't responsible, but I suppose anything is possible! :)@C. Watford – I agree there are subtle ST/T abnormalities on this ECG. The T-waves are right in that border-zone between hyperacute looking and hyperkalemic. They're symmetrical with a slightly late take-off. Hard call! But definitely not an obvious STEMI. On the other hand, post-arrest he bought himself a trip to the cath lab just the same! @SoCal Medic – I'm not convinced that's an actual PVC, but other than that I don't have anything to add to your comments. I think ST/T wave abnormalities have to be taken with a little grain of salt post-arrest! @Jesse – I'm starting to feel like a minority view with regard to this PVC! :)@Brian T – Very nice update. This was our first case for the Cardiac Arrest Registry to Enhance Survival (CARES). I think the paramedics didn't perform 2 minutes of CPR prior to the first shock because the patient was located < 1 min. from the fire station. It wasn't until we crunched the data that we realized the "call received" to "first shock" interval was in the 7 minute range. On the other hand, in the old days we would have just shocked with no CPR at all! In this case, chest compressions were started immediately while the monitor/defibrillator was prepared. The first rescuer on scene actually performed 74 continuous compressions prior to the first shock, which is probably a key reason this gentleman is alive today!

  • no tennis ball to the chest, right?

  • Tom B says:

    Ah, good point! No tennis ball to the chest.

  • or tennis racket in doubles… hee hee.

  • Hillis says:

    Very nice case ,i would not consider the STE in the V3-4 is significant for hyperkalemia becouse it’s only localized in these 2leads and about the STD could nonSTEMI myocardial infarction cause such serious complication/ VT /- Can’t wait to read the conclusion .. Many thanks

  • Ryan says:

    Wouldn’t change much from the previous posts…I’ll stick with it being a PVC, though, we are post arrest and the heart is going to be angry and irritable, I would expect many more than one PVC. I’ll give the 150mg of Amio over 10 minutes, H’s/T’s, serial 12 leads, and just maintain the goodness we have going right now, manage any changes we come across, watch for development of pneumothoracies following the chest compressions, transport to the closest PCI hospital……life is good otherwise.

  • firemedic24 says:

    are those delta waves I see?

  • MedicDude89 says:

    Ya, that "R on T PVC" is way too narrow to be a real PVC, just doesn't have the right morphology. I'm definitely thinking its just artifact, especially beause it does not interfere with the R-R of the next expected sinus beat, or that beat's morphology.

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