II. Causes
III. Differential Diagnosis
- Pseudo-Electromechanical Dissociation (Pseudo-EMD)
- Obese patients with Hypotension may have pulses difficult to palpate and may appear to be in EMD or PEA
- Bedside Emergency Echocardiogram can distinguish from EMD (e.g. cardiac standstill)
- Empiric fluid bolus and consider Vasopressors
IV. Management: Adults and children (ACLS)
- See Asystole (identical Epinephrine protocol)
- Assess Blood Flow
- Consider causes as above and treat appropriately
- See Reversible Causes of Cardiopulmonary Arrest (5H5T)
- Most PEA patients have organized cardiac activity, but have a Blood Pressure too low to detect via pulse
- On Bedside Ultrasound, 85% of PEA patients have mechanical cardiac contractions (see Pseudo-EMD above)
- Bocka (1988) Ann Emerg Med 17(5): 450-2 [PubMed]
- Fluid bolus (single most likely intervention to reverse PEA)
- Consider Vasopressors (e.g. Epinephrine infusion)
- Maximize oxygenation and ventilation (place Advanced Airway)
- Decompress Tension Pneumothorax
- Pericardiocentesis for Cardiac Tamponade
- Fibrinolytics if massive Pulmonary Embolism or Myocardial Infarction is suspected
- Massive Pulmonary Embolism causes 5-10% of PEA arrests
- TPA (50 mg IV) given early (mean 6 min from start of CPR) for high suspicion PE had 85% longterm survival
V. Protocol: Littmann Approach
- Background
- Simplified and more directed approach to PEA compared with ACLS
- Eliminates Hypoglycemia and Hypokalemia from the 5H5T algorithm (unlikely to present with PEA)
- Eliminates Hypothermia and Hypoxia from the 5H5T algorithm (identified readily with other measures and history)
-
Electrocardiogram with NARROW QRS Complex
- Bedside Cardiac Ultrasound
- Hyperdynamic left ventricle
- Causes: Right ventricular inflow or outflow problems
- Cardiac Tamponade
- Tension Pneumothorax
- Mechanical hyperinflation (e.g. COPD)
- Pulmonary Embolism
- Severe Hypovolemia
- Acute Myocardial Infarction with myocardial rupture
- Management
- Intravenous Fluid bolus AND
- Treat underlying cause (e.g. needle decompression, Thrombolytics, Pericardiocentesis)
- Precautions
- Aggressive Mechanical Ventilation and Chest Compressions may exacerbate RV inflow and outflow obstruction
- Bedside Cardiac Ultrasound
-
Electrocardiogram with WIDE QRS Complex
- Bedside Cardiac Ultrasound
- Hypokinetic or akinetic left ventricle
- Causes: Toxic or Metabolic problem
- Severe Hyperkalemia
- Sodium-channel blocker toxicity
- Agonal rhythm
- Acute Myocardial Infarction with pump failure
- Management
- Empiric Calcium Chloride IV and Sodium Bicarbonate IV
- Treat specific causes
- Bedside Cardiac Ultrasound
- References
VI. Prognosis
- PEA survival is very poor (8.8% in one study)
- Good neurologic outcome in only 6.5%
- Heart Rate and QRS width do not appear to alter survival
- Hauck (2015) Am J Emerg Med 33(7): 891-4 +PMID: 25943040 [PubMed]
VII. References
- Mattu and Orman in Herbert (2014) EM:Rap 14(8): 2-3
- Pediatric Resucitation
- Cardiopulmonary Resuscitation Guidelines