Pulseless Electrical Activity (PEA)

Pulseless Electrical Activity (PEA)

David Ray Velez, MD

Cardiac Arrest in Which the Heart’s Electrical Activity is Unable to Produce a Pulse

  • Previously Known as Electromechanical Dissociation (EMD)

Definitions

  • True PEA/EMD: Heart Has Electrical Activity but Does Not Respond (Cardiac Standstill with No Blood Flow)
  • Pseudo-PEA: Heart Has Electrical Activity but the Cardiac Output is Profoundly Low and Not Effective or Strong Enough to Produce a Palpable Pulse

EKG Findings

  • Sufficient Electrical Discharge to Maintain a Notable Rhythm
  • *No Palpable Pulse

Reversible Causes of Sudden Cardiac Arrest: “5 H’s and T’s”

  • 5 H’s:
    • Hypovolemia
    • Hypoxia
    • Hydrogen Ions (Acidosis)
    • Hypokalemia/Hyperkalemia
    • Hypothermia/Hyperthermia
  • 5 T’s:
    • Tension Pneumothorax
    • Trauma and Toxins
    • Tamponade (Cardiac)
    • Thrombosis (Pulmonary/PE)
    • Thrombosis (Coronary/MI)
  • “H’s and T’s” are More Often are Associated with PEA Than Asystole

Pulse Detection

  • Place an Arterial Line Early for Accurate Monitoring and Recognition of Pseudo-PEA
  • “Pseudo-PEA” Does Not Require CPR
  • Causes of Failure to Detect a Present Pulse:
    • Hemodynamic Instability with Significant Hypotension
    • Morbid Obesity
    • Severe Peripheral Arterial Disease
    • Nurses and Providers in General are Poor at Accurately Performing Pulse Checks in Cardiac Arrest (Studies Show High Levels of Inaccuracy and Prolonged Time to Diagnose)

Treatment

  • Follow ACLS Guidelines: *See Cardiac Arrest
  • Start CPR Immediately and Give Oxygen
  • Treat Any Reversible Causes
  • Check Rhythm Every 2 Minutes
    • PEA is Not a Shockable Rhythm
  • Epinephrine: 1 mg IV/IO, Repeat Every 3-5 Minutes
  • Adjuncts:
    • Calcium Chloride
      • Dose: 1 g IV
      • Vasopressor and Inotropic Effects
      • Not Routinely Given but May Be Considered
    • Sodium Bicarbonate
      • Dose: 50-100 mEq IV (1-2 Amps/Ampules)
      • Can Mitigate the Effects of Acidosis and Hyperkalemia
      • Not Routinely Given but May Be Considered if Concerned for Significant Acidosis or Hyperkalemia

Cardiac Arrest Management Algorithm:

Immediate CPR and Oxygen

Check Rhythm Every 2 Minutes:

  • VF/pVT:
    • Defibrillate
    • Alternate Epinephrine and Amiodarone After Each Check
  • PEA/Asystole:
    • Epinephrine After Every Other Check

Adjuncts:

  • Calcium Chloride
  • Sodium Bicarbonate