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Pulseless Electrical Activity
Aka: Pulseless Electrical Activity, PEA Rhythm, Electromechanical Dissociation, Idioventricular Rhythm, Bradyasystolic Rhythm, Pseudo-EMD
- See Also
- Cardiopulmonary Resuscitation
- Ventricular Fibrillation
- Asystole
- Causes
- See Reversible Causes of Cardiopulmonary Arrest (5H5T)
- 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
- Management: Adults and children (ACLS)
- See Asystole (identical Epinephrine protocol)
- However empiric cause management differs from Asystole (see below)
- Atropine is no longer indicated for slow PEA (as of 2010)
- Assess Blood Flow
- Doppler Ultrasound
- End-Tidal CO2
- Echocardiography
- Arterial Line
- 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
- Sharifi (2016) Am J Emerg Med 34(10):1963-7 +PMID: 27422214 [PubMed]
- 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
- 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
- References
- Littmann (2014) Med Princ Pract 23(1):1-6 [PubMed]
- 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]
- References
- Mattu and Orman in Herbert (2014) EM:Rap 14(8): 2-3
- Pediatric Resucitation
- http://pediatrics.aappublications.org/content/126/5/e1361.full.html
- (2010) Pediatrics 126(5): e1361 [PubMed]
- Cardiopulmonary Resuscitation Guidelines
- http://www.circulationaha.org
- (2010) Guidelines for CPR and ECC [PubMed]
- (2005) Circulation 112(Suppl 112):IV [PubMed]
- (2000) Circulation, 102(Suppl I):86-9 [PubMed]