sudden cardiac arrest is linked more with structural heart disease ; however it is also associated with pulmonary embolism ( pe ) . the conventional treatment of pe is anticoagulation but the risk of bleeding is high in the situations where patients undergo prolonged cardiac arrest and hypothermia management . we hereby , present the unique case of pulmonary embolism diagnosed on the basis of clinics and bedside echocardiogram during a prolonged cardiopulmonary resuscitation ( cpr ) , needing hypothermia management , and associated with rapid and remarkable recovery after administration of a loading dose of tissue plasminogen activator ( tpa ) without any complication of bleeding . a 52-year - old non - smoking caucasian male , who is allergic to shrimps , presented to the emergency room ( er ) after he was found unconscious in the bathroom . at 6 days before presentation , patient had symptoms of severe cough with streaks of blood and dyspnea on exertion and was treated with azithromycin antibiotic for presumed upper respiratory tract infection . the day before presentation , patient 's symptoms of cough and dyspnea started getting worse . patient reported taking benzonatate antitussive , which caused tingling and numbness around his mouth and cheeks , which resolved spontaneously after 30 min . patient did not report of hives , swelling of the face or tongue and difficulty in swallowing . subsequently , patient got extremely agitated and short of breath leading to state of unconsciousness . emergency medical services were activated , 100% oxygen was initiated and patient was transferred to our er . in the er , patient presented with grey colored skin and symptoms of severe dyspnea . as per the patient 's wife , he had no calf pain and/or swelling recently . there were no recent hospitalizations , prolonged immobilization or history of pulmonary embolism ( pe ) and/or deep vein thrombus ( dvt ) . patient 's father has a history of pe secondary to extensive airplane travel and stroke . an electrocardiogram showed a right bundle branch block and st - segment elevations in the inferior leads with elevated troponins of 13.5 ng / ml ( normal < 0.03 ng / ml ) . cardiac monitor showed pulseless electric activity and patient was intubated and cardiopulmonary resuscitation ( cpr ) was initiated immediately . the cardiac arrest was presumed from st elevation myocardial infarction and the patient was transferred to cardiac catheterization laboratory . patient intermittently remained in cardiac arrest requiring intra - aortic balloon pump and temporary pacemaker . cardiac catheterization showed non - obstructive coronary arteries and a hyper - dynamic left ventricle . patient 's blood pressure remained low and so patient was continued on epinephrine , dopamine drips . patient was then transferred to the intensive care unit and he remained intubated with mechanical ventilation and ongoing cpr . on physical examination , the patient was noted to have respiratory rate of 30 breaths / min , fixed and dilated pupils of 7 mm and endotracheal tube in place . cardiac auscultation was tachycardia with no murmurs , gallops and rubs . on neurologic al examination , the patient 's glasgow coma scale was < 9 with no gag reflex and response to babinski . laboratory data revealed white cell count of 11.7  10/l ( normal 4.3 - 10  10/l ) with the normal differentials , creatinine of 2.4 mg / dl ( normal 0.7 - 1.3 mg / dl ) , ionized calcium of 4.0 mg / dl ( normal 4.6 - 5.1 mg / dl ) bicarbonate of 15 mmol / l ( normal 22 - 30 mmol / l ) , serum osmolality of 322 mosm / kg ( 275 - 295 mosm / kg ) , anion gap of 21 mmol / l ( normal 8 - 16 mmol / l ( normal 0.7 - 2.1 mmol / l ) and d - dimer of 6.68 g / ml ( normal < 0.49 g / ml ) . other blood cell counts , liver function tests , alcohol , salicylate , methanol levels and urine toxicology screen were unremarkable . an arterial blood gas showed a ph of 6.8 , pco2 of 70 mmhg , po2 of 90 mmhg on mechanical ventilation , consistent with mixed respiratory and metabolic acidosis . patient 's clinical symptoms , laboratory investigations , negative cardiac catheterization of obstructive coronary arteries , electrocardiogram showing sinus tachycardia and echocardiogram proving hypo kinesis and enlargement of right ventricle suggested presumed diagnosis of pe causing cardiac arrest . at the same time , alteplase , tissue plasminogen activator ( tpa ) was administered immediately with the dose of 0.6 mg / kg over 2 min in a bolus form and heparin drip was started . during the course of the intensive care stay , patient was treated with hypothermic protocol for cardiac arrest with no bleeding complications . intravenous sodium bicarbonate and calcium chloride were given , cardiac arrest was eventually terminated and patient got extubated . the blood pressure got stabilized and dopamine , epinephrine drips were stopped . repeated arterial blood gases within an hour were improved and revealed ph of 7.15 , pco2 of 47 mmhg and po2 of 404 mmhg . venous doppler 's of the lower extremities showed dvt in the left distal femoral vein , gastrocnemius , peroneal vein and normal right lower extremity . the inferior vena cava filter was placed to prevent further occurrence of life - threatening clots or pulmonary embolus and heparin drip was continued . the renal failure secondary to the cardiogenic shock improved with 2 mg of bumetanide , oral diuretic therapy . during the hospital course , heparin was discontinued due to patient 's low platelet count and positive heparin induced thrombocytopenia panel . rivaroxaban , the oral anticoagulant was initiated and patient was transferred to floor with oxygen saturation of 95% on room air . on the medical floor , patient was walking and moving around , could talk in full sentences , was able to feed himself . within 3 days of the hospital stay , he showed remarkable clinical and functional improvement and was discharged to home in a stable condition . sudden cardiac arrest ( sca ) and sudden cardiac death ( scd ) is defined as a sudden termination of cardiac activity with hemodynamic instability requiring immediate cpr . it has become a serious clinical and public health issue . despite advancement in the clinical and research medicine , united states ( us ) vital statistics mortality data due to sca and scd the published death data reports that 15% of the total mortality in the us and other industrialized countries is secondary to sca . sudden death , in majority of the cases comprise of lethal coronary heart disease , which account for 70% of the total and approximately 10 - 15% of the cases are secondary to other structural heart disease including cardiomyopathies , arrhythmias and valvular abnormalities . rest of the non - cardiac causes of sca are attributed to bleeding , infections and familial scd of uncertain cause . pe is also a possible non - cardiac cause of sca associated with very high mortality and often revealed by autopsy . cpr with skillful chest compressions and early defibrillation remains the cornerstone of basic and advanced cardiac life support . the mechanism of sca and its outcome largely depends on the underlying cause , hypoxemia , severe acid base imbalance and the duration of resuscitation ( usually prolonged if it is more than 4 min ) . sca mortality is largely associated with brain death and most of the reported data justifies the role of mild therapeutic hypothermia with its neuroprotective effect . the risk of bleeding is highly associated with hypothermia management , especially if thrombolysis or cardiac intervention has to be done . bedside echocardiogram is a useful diagnostic tool to determine heart valve and pericardium integrity , ventricular function and to differentiate kinds of shock . coronary catheterization and emergency percutaneous coronary intervention remains the principal approach for the resuscitated patients presenting with st - segment elevation and high troponins . important is to consider pulmonary emboli , which can be the underlying cause of the same presentation . although , sca is linked more with structural heart disease , association with pe remain under high suspicion . acute pe is an extremely fatal disease , if not early diagnosed and treated appropriately . clinical presentation is highly variable and is often associated with sinus tachycardia in electrocardiogram and arterial blood gases showing hypoxemia , hypocapnia and respiratory alkalosis . serum troponin i and troponin t are found elevated in 30 - 50% of patients with pe . though , confirmed diagnosis is attained by angiography , chest computed tomography with contrast if not contraindicated or ventricular perfusion scan , bedside echocardiogram has a remarkable role in emergency cases . there are several reported cases of favorable outcomes associated with thrombolysis in presumed or confirmed diagnosis of pe during cardiac arrest . we hereby , present the unique case of pe diagnosed on the basis of clinics and bedside echocardiogram during a prolonged cpr , needing hypothermia management and associated with rapid and remarkable recovery after administration of a loading dose of tpa without any complication of bleeding . in this patient , the presence of clinical signs of dyspnea and hemoptysis , sinus tachycardia on electrocardiogram , elevated troponins and bedside echocardiogram showing enlargement and hypokinesis of the right ventricle , suggested the diagnosis of pe as an underlying cause of prolonged cardiac arrest , which prompted to start tpa , despite the risk of bleeding associated with the hypothermia management . this case illuminates the precedence of early initiation of tpa with the expeditious diagnosis of pe , along with prolonged cpr and hypothermia treatment .