Case Presentation and Resuscitation
A 45-year-old patient arrived in the emergency department after collapsing, with cardiac arrest reported 10 minutes before arrival. The patient was unresponsive, without a central pulse or measurable blood pressure. The team started CPR, obtained IV access, intubated the patient, and continued monitoring.
The initial rhythm was ventricular fibrillation (VF), and repeated shocks were delivered. The narrative mentions two shocks before reporting amiodarone doses of 300 mg and 150 mg; the timing of the individual doses is unclear. VF continued to be reported during resuscitation. Double sequential external defibrillation (DSED) was not used, in accordance with hospital policy.
Case-documentation limit: Confirm the shock and drug timestamps from the record rather than reconstructing them. For shockable arrest in the AHA 2025 adult algorithm, epinephrine enters after the second shock and amiodarone after the third; the amiodarone doses are 300 mg, then 150 mg if needed. ERC 2025 gives epinephrine after the third shock. Both use epinephrine 1 mg every 3–5 minutes during arrest. These are current recommendations, not confirmation of what happened in this case.
At 20 minutes of CPR, bedside echocardiography reportedly showed cardiac motion without a palpable central pulse. The case describes this as pseudo-PEA. CPR continued, epinephrine was given every 4 minutes, and normal saline and norepinephrine were administered. The ECG rhythm at that moment, fluid volume, norepinephrine dose, and their precise timing are not provided.
At approximately 40 minutes of CPR, a very weak pulse was detected and ROSC was reported. Blood pressure was 80/50 mmHg, heart rate 60/min, and pupils were normal-sized and reactive.
Cardiology was consulted for suspected ischemic heart disease. Angiography showed a significant left anterior descending coronary artery lesion, which was stented. An intra-aortic balloon pump (IABP) was also used. Temperature management, described in the case as therapeutic hypothermia, followed. The patient reportedly recovered; the narrative does not specify a neurological outcome score or follow-up duration. This sequence cannot establish which intervention caused recovery.
Cardiac motion is not the same as effective perfusion
Pseudo-PEA describes an organized electrical rhythm with cardiac motion but no palpable pulse. Contraction may produce too little forward flow to generate a detectable pulse. Here, without the contemporaneous ECG, the label remains unconfirmed: ultrasound motion alone cannot distinguish the electrical rhythm. Clinical cohort and terminology.
If circulation is uncertain, continue CPR. A skilled operator can record a brief ultrasound clip within an already planned rhythm check and interpret it after compressions resume; do not create or lengthen pauses. Use findings to investigate reversible causes, not to replace ECG and perfusion assessment. A rise in ETCO₂ may suggest ROSC but is insufficient alone to stop compressions. Neither low ETCO₂ nor absent echo motion should independently determine termination. ERC 2025 ALS.
The fluids and norepinephrine above are case history, not a routine pseudo-PEA regimen. During arrest, fluid treatment should address suspected hypovolemia; motion alone does not demonstrate fluid responsiveness. Norepinephrine is not a substitute for algorithm-directed epinephrine. ERC guidance; AHA guidance.
Take-Home Points
- Protect the basics: Defibrillate VF/pVT promptly, resume compressions immediately, and check pad position, contact, and device-appropriate energy. Repeated VF on rhythm checks may reflect recurrence after successful shocks rather than continuous shock failure. AHA 2025.
- Know the guideline differences: For VF/pVT persisting after at least three consecutive shocks, ILCOR 2025 permits consideration of DSED or vector change, with weak recommendations and low or very-low certainty, respectively. AHA 2025 considers the usefulness of both unestablished. ERC 2025 supports considering vector change after checking standard pad placement, but does not recommend routine DSED. Follow the adopted protocol and device-safety requirements.
- ROSC begins the next phase: BP 80/50 mmHg still indicates hypotension. Reassess perfusion, ventilation, and the cause of arrest. IABP and hypothermia are reported treatments here, not universal post-arrest requirements. Current care individualizes circulatory support and uses protocolized temperature control for patients who remain unresponsive to verbal commands. AHA post-arrest care.
