This article is a quasi-cross-post from the website of our good friend Brandon Oto at EMS Basics. He’s been gracious enough to allow us to adapt the original post from his What it Looks Like series over here. We suggest that you go check out the work he does on his site; it’s the epitome of the quality content even a solo blogger can put together in the world of EMS 2.0 and FOAM. (Update 3/30/2017: Brandon now writes at critcon.org; it’s amazing, of course).
We all know the fundamentals of Basic Life Support (BLS), a lot of us have taken Advanced Cardiac Life Support (ACLS), and some among us have even accrued a enviable collection of other advanced resuscitation course merit badges. In spite of that, healthcare workers of all fields, training, and experience can stumble when it comes to that most fundamental of steps in the CPR algorithm: recognizing cardiac arrest.
We have assembled some of the best videos available on YouTube that display the physical signs you will encounter when a patient experienced sudden cardiac arrest right in front of you. Thankfully most, but not all, of the patients depicted recovered, and we owe a huge debt to the patients and their families who allowed the footage to be released.
This post isn’t meant to be a critique of the way the codes were managed or how well compressions were performed; we just want to examine what it looks like when a person experiences cardiac arrest so that you can recognize it immediately.
[To save you time all of the videos link to a point just prior to the patient arresting, but we still suggest watching the surrounding footage.]
The Chris Solomon Rescue
Chris Solomon arrived to his morning shift as a dispatcher with the Yorkshire Air Ambulance feeling a bit unwell. He began to develop chest pain and thankfully his colleagues were there to assess him, perform a 12-lead ECG, and recognize that he was experiencing a STEMI. This entire video is an absolute must-see but take special note of the events surrounding his cardiac arrest.
You’ll note that at exactly 2:18 in the video Chris goes into a V-fib cardiac arrest. There’s no giant display, he just sort of nods off. If you listen closely you can also hear agonal respirations.
As the crew lowers him to the ground you’ll notice that he immediately begins posturing and displaying the kind of movements that we often associate with seizures. Even as they begin CPR his arms are still moving but make no mistake, and the medics certainly didn’t hesitate, Chris is in cardiac arrest. Even through the first and second defibrillation he maintains his posturing and agonal respirations.
As we see here is not uncommon for a patient to be moving and breathing with their eyes open during a sudden cardiac arrest if high-quality CPR is started early. It is certainly unsettling to perform CPR on someone who seems to be looking at you, but it’s becoming more common and it means that the good-quality CPR is being performed.
This is an amazing save and these providers set a high bar for running a resuscitation, even as it catches them completely off guard in their own dispatch station.
Syncope vs. seizure — at times it is nearly impossible to differentiate the two. That is, unless you have the patient hooked up to a cardiac monitor and video EEG.
This is the case of a 25-year-old female who was referred to a video EEG unit for workup and differentiation of a seizure disorder that was diagnosed eight years prior. When startled she would experience episodes of anxiety and lightheadedness with palpitations before becoming unconscious. One of these episodes was caught while in the video EEG unit. The bottom line displayed on the monitor is her EKG.
This video is hard to watch but that’s a good thing; it means that you’re not comfortable watching someone in cardiac arrest not receive immediate CPR. To ease your mind a bit I will tell you ahead of time that she had a full recovery.
At 0:38 in the video the patient goes into torsades de pointes. She begins to feel symptoms and rings her call bell.
She soon becomes unresponsive and begins hyperventilating. This is cardiac arrest and you are seeing very pronounced agonal respirations.
The unit staff, used to seeing and assessing seizures and having been informed that this is what her “seizures” look like, arrive and begin their seizure assessment. Unfortunately there is no cardiac monitor in the room and they do not routinely check pulses on their seizure patients.
At 2:10 she becomes fully apneic except for the occasional agonal breath. Her EEG also shows a flat-line, indicating a cessation of brain activity. More staff arrive and place her in the recovery position and at about 2:23 she spontaneously reverts to normal sinus.
After this event her TdP was recognized and she was diagnosed with a variant of long-QT syndrome, though her resting EKG only had a QTc of 430-480 ms. She chose not to receive an ICD at that time but responded to medical therapy and is apparently doing well.
This case emphasizes the importance of considering cardiac arrest in anyone presenting with a “seizure.” It also shows that humans can exhibit agonal respirations for a surprisingly long amount of time after cardiac arrest, even with no detectable brain activity on an EEG.
This older video, shot for the TLC show “Paramedics,” shows EMS responding to a patient at a local hotel with a chief complaint of chest pain.
Soon after EMS arrival, at about 2:05 in the video, he becomes unresponsive and begins exhibiting agonal respirations. Unsurprisingly, the medic’s first question is whether he has a history of seizures.
This is an extremely common mistake (see the last case).
As he lays back at 2:10 you can see the patient exhibiting posturing very similar to Chris Solomon’s. As they move him to the stretcher the respirations continue and the crew tries to talk to him, apparently still not realizing he is in cardiac arrest. It doesn’t take long to rectify that, however, and he is defibrillated back into a perfusing rhythm.
He was awake and responsive on arrival at the hospital so it seems likely that he had a good outcome.
This video is from the Australian show “Bondi Rescue.” A local man was doing his usual swim at the beach when he started to experience classic cardiac chest pain and requested aid from the lifeguards. Trained in BLS, they called EMS and applied an AED because they recognized the high likelihood of the patient going into cardiac arrest before medics arrived.
At 1:14 in the video, just as the medics arrive on scene, the patient states that he feels like he is going to pass out and goes into cardiac arrest. As in the other cases, he keeps breathing at the start of his arrest and at 1:40 you can clearly see his left arm stiff and raised, in posturing almost exactly like Chris Solomon demonstrated.
Thankfully he responded well to defibrillation and had an excellent outcome. At the hospital they performed an aspiration thrombectomy of a culprit lesion in one of his coronary arteries with immediate resolution of his symptoms and he was well enough to visit the lifeguard station a short time later.
This video is from the show “Heroes Among Us.” The patient involved was playing basketball with some friends when he suddenly collapsed on the court due to a sudden cardiac arrest. As you can see in the video, after his collapse he was still breathing and the folks nearby thought he was having a seizure. Hopefully you’re noticing a trend at this point.
A bystander, who happened to be a physician, was walking by and noticed the scene. At 2:20 in the video the patient was still breathing but the physician quickly checked a pulse, didn’t find one, and began immediate CPR.
Yet again, early recognition and early CPR probably contributed to this man having a good outcome and getting back to the point where he could return to playing basketball.
This isn’t true cardiac arrest but it’s a great example of exactly what cardiac arrest can sometimes look like so I had to include it. Plus, it’s pretty much the same mechanism that produces unconsciousness during arrest — global cerebral hypoxia — hence it looks the same, just with a different resolution.
This video shows a diver who experienced significant hypoxia and blacked-out. As you can see, he exhibits pronounced agonal respirations and posturing-type movements that could easily be confused for a seizure.
In this case, after breathing air for a few seconds, he quickly returned back to baseline, just as a typical syncope patient recovers after falling flat.
This is a hard case to discuss. First, it’s only video on our list so far that shows someone who died from their sudden cardiac arrest. Second, we won’t get into the specifics of how his resuscitation was handled, but if you look into Hank Gathers’ story you’ll find that a number of factors aligned that really set him up for a bad outcome.
One factor visible here is that his cardiac arrest was not recognized for a significant amount of time, despite having a known history of malignant arrhythmias.
At 0:37 in the video you see Hank Gathers collapse. He is in cardiac arrest but clearly breathing and exhibiting sporadic muscle movements. After a few seconds he even manages to sit up but quickly collapses back to the court and exhibits seizure-like activity. This ceases a short time later and a couple of minutes after his collapse he is taken off the court, having not yet received any CPR.
Anthony Van Loo
This case has a good outcome. Anthony Van Loo was diagnosed with hypertrophic cardiomyopathy (the same condition that killed Hank Gathers) but was able to resume play after receiving an implantable cardioverter-defibrillator (ICD). This video shows Anthony, in the top-center of frame, experiencing a sudden cardiac arrest on the field. After a few seconds his ICD shocks him back into a normal rhythm and he recovers almost immediately.
This case emphasizes both how quickly and innocuously sudden cardiac arrest can strike (Anthony had no prodrome and showed no readily apparent signs of life on hitting the ground) and how well patients can recover with prompt defribrillation.
This is exactly what we are attempting to replicate in our patients who collapse without an ICD, using CPR to buy time until the defibrillation can arrive.
Another footballer, Miguel Garcia, also collapsed during a match in sudden cardiac arrest. In the video below you can see him in the far-left background at the 0:18 mark when he starts jogging and suddenly falls to the ground.
Thankfully he also had a good outcome and made a full recovery. Sadly, there are many cases of soccer players experiencing cardiac arrest that were caught on camera (and many more that aren’t) who never recovered, and there is one more in particular we would like to discuss.
One last tragic case with a very important lesson.
As in the past few videos, Antonio Puerta collapsed suddenly during a match. In this video you can see him crouching down before falling over unresponsive.
Soon after the arrival of his teammates and trainers he spontaneously recovered and was actually able to walk back to the locker room.
Syncope is a huge red-flag, especially when it occurs during exercise.
Benign causes of syncope and self-resolved cardiac arrest are undifferentiable from outward appearance. In this case Anthony Puerta experienced a sudden cardiac arrest that resolved on his own. Despite looking perfectly well, only a short time after walking himself back to the locker room he collapsed again and could not be resuscitated. The arrhythmias that he experienced were secondary to arrhytmogenic right ventricular dysplasia (ARVD).
It’s heavy work watching these sorts of videos but it’s important for what we do. Prompt recognition of cardiac arrest is the first link in the Chain of Survival and early CPR and defibrillation are absolutely vital to achieving good outcomes for these patients. Here’s a few final take-home points:
- Sudden cardiac arrest is just that — sudden — and can occur without warning.
- It is surprisingly difficult to differentiate seizures from early cardiac arrest.
- Sudden cardiac arrest that self-resolves is called syncope (H/T to Amal Mattu).
- It is nearly impossible to distinguish benign syncope from cardiac arrest until the patient recovers and a thorough history, examination, and workup can be performed.
- Any patient presenting with syncope or seizure needs, at the minimum, an EKG.