III. Differential Diagnosis

  1. Pseudo-Electromechanical Dissociation (Pseudo-EMD)
    1. Obese patients with Hypotension may have pulses difficult to palpate and may appear to be in EMD or PEA
    2. Bedside Emergency Echocardiogram can distinguish from EMD (e.g. cardiac standstill)
    3. Empiric fluid bolus and consider Vasopressors

IV. Management: Adults and children (ACLS)

  1. See Asystole (identical Epinephrine protocol)
    1. However empiric cause management differs from Asystole (see below)
    2. Atropine is no longer indicated for slow PEA (as of 2010)
  2. Assess Blood Flow
    1. Doppler Ultrasound
    2. End-Tidal CO2
    3. Echocardiography
    4. Arterial Line
  3. Consider causes as above and treat appropriately
    1. See Reversible Causes of Cardiopulmonary Arrest (5H5T)
    2. Most PEA patients have organized cardiac activity, but have a Blood Pressure too low to detect via pulse
      1. On Bedside Ultrasound, 85% of PEA patients have mechanical cardiac contractions (see Pseudo-EMD above)
      2. Bocka (1988) Ann Emerg Med 17(5): 450-2 [PubMed]
    3. Fluid bolus (single most likely intervention to reverse PEA)
    4. Consider Vasopressors (e.g. Epinephrine infusion)
    5. Maximize oxygenation and ventilation (place Advanced Airway)
    6. Decompress Tension Pneumothorax
    7. Pericardiocentesis for Cardiac Tamponade
    8. Fibrinolytics if massive Pulmonary Embolism or Myocardial Infarction is suspected
      1. Massive Pulmonary Embolism causes 5-10% of PEA arrests
      2. TPA (50 mg IV) given early (mean 6 min from start of CPR) for high suspicion PE had 85% longterm survival
        1. Sharifi (2016) Am J Emerg Med 34(10):1963-7 +PMID: 27422214 [PubMed]

V. Protocol: Littmann Approach

  1. Background
    1. Simplified and more directed approach to PEA compared with ACLS
    2. Eliminates Hypoglycemia and Hypokalemia from the 5H5T algorithm (unlikely to present with PEA)
    3. Eliminates Hypothermia and Hypoxia from the 5H5T algorithm (identified readily with other measures and history)
  2. Electrocardiogram with NARROW QRS Complex
    1. Bedside Cardiac Ultrasound
      1. Hyperdynamic left ventricle
    2. Causes: Right ventricular inflow or outflow problems
      1. Cardiac Tamponade
      2. Tension Pneumothorax
      3. Mechanical hyperinflation (e.g. COPD)
      4. Pulmonary Embolism
      5. Severe Hypovolemia
      6. Acute Myocardial Infarction with myocardial rupture
    3. Management
      1. Intravenous Fluid bolus AND
      2. Treat underlying cause (e.g. needle decompression, Thrombolytics, Pericardiocentesis)
    4. Precautions
      1. Aggressive Mechanical Ventilation and Chest Compressions may exacerbate RV inflow and outflow obstruction
  3. Electrocardiogram with WIDE QRS Complex
    1. Bedside Cardiac Ultrasound
      1. Hypokinetic or akinetic left ventricle
    2. Causes: Toxic or Metabolic problem
      1. Severe Hyperkalemia
      2. Sodium-channel blocker toxicity
      3. Agonal rhythm
      4. Acute Myocardial Infarction with pump failure
    3. Management
      1. Empiric Calcium Chloride IV and Sodium Bicarbonate IV
      2. Treat specific causes
  4. References
    1. Littmann (2014) Med Princ Pract 23(1):1-6 [PubMed]

VI. Prognosis

  1. PEA survival is very poor (8.8% in one study)
    1. Good neurologic outcome in only 6.5%
    2. Heart Rate and QRS width do not appear to alter survival
    3. Hauck (2015) Am J Emerg Med 33(7): 891-4 +PMID: 25943040 [PubMed]

Images: Related links to external sites (from Bing)

Related Studies

Ontology: Electromechanical dissociation (C0340861)

Definition (NCI_FDA) Continued electrical rhythmicity of the heart in the absence of effective mechanical function.
Definition (NCI) An electrocardiographic finding of the presence of cardiac electrical rhythm without a proper response of the myocardial tissue and mechanical cardiac output.
Concepts Disease or Syndrome (T047)
SnomedCT 195089000, 234172002
LNC LA17070-6
English Card arrest-electromech disoc, PEA, Electromechanical Dissociation, Pulseless Electrical Activity, Electromechanical dissociation, Electro-Mechanical Dissociation, electromechanical dissociation (diagnosis), electromechanical dissociation, electromechanical dissociation (EMD), pulseless electrical activity, emd, Electromechanical Dissociation by ECG Finding, ELECTRO-MECHANICAL DISSOCIATION, Electromechanical Dissociation by EKG Finding, DISSOCIATION, ELECTRO-MECHANICAL, Cardiac arrest with electromechanical dissociation, Electromechanical dissociation (disorder), Pulseless electrical activity, EMD, PEA - Pulseless electrical activity
Spanish Actividad eléctrica sin pulso, Disociación electromecánica, disociación electromecánica (trastorno), disociación electromecánica, paro cardíaco con disociación electromecánica
Portuguese Actividade eléctrica sem pulso, Dissociação electromecânica
Italian Attività elettrica senza polso, Dissociazione elettromeccanica
German elektromechanische Dissoziation, pulslose elektrische Aktivitaet
French Dissociation électromécanique, Activité électrique sans impulsion
Dutch polsloze elektrische activiteit, elektromechanische dissociatie
Czech Elektromechanická disociace
Japanese 電気収縮解離, デンキシュウシュクカイリ, ムミャクセイデンキカツドウ, 無脈性電気活動
Hungarian Pulzus nélküli elektromos aktivitás, Electromechanikus dissociatio

Ontology: Idioventricular rhythm (C0700363)

Definition (NCI) An electrocardiographic finding of three or more consecutive complexes of ventricular origin with a rate less than a certain threshold (100 or 120 beats per minute are commonly used). The QRS complexes are wide and have an abnormal morphology. (CDISC)
Definition (NCI_CDISC) An electrocardiographic finding of three or more consecutive complexes of ventricular origin with a rate less than a certain threshold (100 or 120 beats per minute are commonly used). The QRS complexes are wide and have an abnormal morphology.
Definition (NCI_FDA) Relating to or affecting the cardiac ventricles alone.
Concepts Finding (T033)
SnomedCT 49260003
Italian Ritmo idioventricolare, Ritmo ventricolare
English Rhythm, idioventricular, Idioventricular Rhythm, Idioventricular rhythm, Rhythm idioventricular, idioventricular rhythms, ventricular rhythm, rhythm ventricular, RHYTHM, IDIOVENTRICULAR, IDIOVENTRICULAR RHYTHM, idioventricular rhythm, idioventricular rhythm (diagnosis), ventricular arrhythmia idioventricular rhythm, Ventricular rhythm, Idioventricular rhythm (disorder), idioventricular; rhythm, rhythm; idioventricular, Idioventricular rhythm, NOS, Ventricular rhythm, NOS, Ventricular rhythm (disorder)
Dutch ventriculair ritme, idioventriculair; ritme, ritme; idioventriculair, idioventriculair ritme
French Rythme ventriculaire, Rythme idioventriculaire
German ventrikulaerer Rhythmus, Rhythmus idioventrikulaer
Portuguese Ritmo ventricular, Ritmo idioventricular
Spanish Ritmo ventricular, ritmo idioventricular, ritmo ventricular (trastorno), ritmo ventricular, Ritmo idioventricular
Japanese 心室調律, 固有心室調律, シンシツチョウリツ, コユウシンシツチョウリツ
Czech Idioventrikulární rytmus, Komorový rytmus
Hungarian Ventricularis ritmus, Idioventricularis ritmus