eMedicine Specialties > Cardiology > Arrhythmias

Pulseless Electrical Activity: Differential Diagnoses & Workup

Author: Patrick O'Beirne, MD, Fellow in Cardiovascular Medicine, UMass Memorial Medical Center
Coauthor(s): Dionyssios A Robotis, MD, MPH, FACC, Assistant Professor of Medicine, University of Massachusetts; Consulting Staff Cardiologist/Electrophysiologist, University of Massachusetts Memorial Medical Center; Lawrence Rosenthal, MD, PhD, Associate Professor of Medicine, Director, Section of Cardiac Electrophysiology and Pacing, Fellowship Director of Clinical Cardiac Electrophysiology, Department of Internal Medicine, Division of Cardiovascular Medicine, University of Massachusetts Memorial Medical Center
Contributor Information and Disclosures

Updated: May 11, 2009

Differential Diagnoses

Accelerated Idioventricular Rhythm

Workup

Laboratory Studies

  • Because of the emergent nature of the problem, lab tests are not likely to be helpful in the immediate management of the patient.
  • If available rapidly, arterial blood gases, serum electrolytes, and glucose may provide information regarding serum pH, oxygenation, serum potassium and glucose. 

Imaging Studies

Bedside echocardiography may rapidly identify reversible cardiac problems (eg, cardiac tamponade, rupture, massive myocardial infarction). Echocardiography also identifies patients with weak cardiac contractions who have pseudo-PEA. This group of patients is more likely to benefit from aggressive resuscitation.5

Other Tests

A 12-lead ECG is difficult to obtain during ongoing resuscitation but, if available, can provide clues to the presence of hyperkalemia (eg, peaked T waves, complete heart block, ventricular escape rhythm) or acute myocardial infarction. Hypothermia, if not already diagnosed, may be suspected by the presence of Osborne waves. Certain drug overdoses (eg, tricyclic antidepressants) prolong QRS duration.

Procedures

  • Placement of an arterial line may identify patients with a recordable (but very low) blood pressure; these patients are likely to have a better outcome if given aggressive resuscitation.

More on Pulseless Electrical Activity

Overview: Pulseless Electrical Activity
Differential Diagnoses & Workup: Pulseless Electrical Activity
Treatment & Medication: Pulseless Electrical Activity
Follow-up: Pulseless Electrical Activity
References
Further Reading
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References

  1. Raizes G, Wagner GS, Hackel DB. Instantaneous nonarrhythmic cardiac death in acute myocardial infarction. Am J Cardiol. Jan 1977;39(1):1-6. [Medline].

  2. Nadkarni VM, Larkin GL, Peberdy MA, Carey SM, Kaye W, Mancini ME. First documented rhythm and clinical outcome from in-hospital cardiac arrest among children and adults. JAMA. Jan 4 2006;295(1):50-7. [Medline].

  3. Desbiens NA. Simplifying the diagnosis and management of pulseless electrical activity in adults: a qualitative review. Crit Care Med. Feb 2008;36(2):391-6. [Medline].

  4. Hutchings AC, Darcy KJ, Cumberbatch GL. Tension pneumothorax secondary to automatic mechanical compression decompression device. Emerg Med J. Feb 2009;26(2):145-6. [Medline].

  5. Steiger HV, Rimbach K, Müller E, Breitkreutz R. Focused emergency echocardiography: lifesaving tool for a 14-year-old girl suffering out-of-hospital pulseless electrical activity arrest because of cardiac tamponade. Eur J Emerg Med. Apr 2009;16(2):103-5. [Medline].

  6. Fuzaylov G, Woods B, Driscoll W. Documentation of resuscitation of an infant with pulseless electrical activity because of venous air embolism. Paediatr Anaesth. Nov 2008;18(11):1121-3. [Medline].

  7. Hazinski MF, Nadkarni VM, Hickey RW, O'Connor R, Becker LB, Zaritsky A. Major changes in the 2005 AHA Guidelines for CPR and ECC: reaching the tipping point for change. Circulation. Dec 13 2005;112(24 Suppl):IV206-11. [Medline].

  8. Nichols R, Zawada E. A case study in therapeutic hypothermia treatment post-cardiac arrest in a 56-year-old male. S D Med. Oct 2008;61(10):371-3. [Medline].

  9. Kotak D. Comment on Grmec et al.: A treatment protocol including vasopressin and hydroxyethyl starch solution is associated with increased rate of return of spontaneous circulation in blunt trauma patients with pulseless electrical activity. Int J Emerg Med. Apr 2009;2(1):57-8. [Medline].

  10. Grmec S, Strnad M, Cander D, Mally S. A treatment protocol including vasopressin and hydroxyethyl starch solution is associated with increased rate of return of spontaneous circulation in blunt trauma patients with pulseless electrical activity. Int J Emerg Med. Dec 2008;1(4):311-6. [Medline].

  11. Aufderheide TP, Thakur RK, Stueven HA. Electrocardiographic characteristics in EMD. Resuscitation. Apr 1989;17(2):183-93. [Medline].

  12. Berenyi KJ, Wolk M, Killip T. Cerebrospinal fluid acidosis complicating therapy of experimental cardiopulmonary arrest. Circulation. Aug 1975;52(2):319-24. [Medline].

  13. Chen Q, Scott BH, Bilfinger TV, et al. Pulseless electrical activity after induction of anesthesia: A witnessed cardiac rupture. J Cardiothorac Vasc Anesth. Dec 2004;18(6):767-8. [Medline].

  14. Colwell C, Murphy P, Bryan T. Pulseless electrical activity. Emerg Med Serv. Sep 2004;33(9):63-6, 68. [Medline].

  15. Herlitz J, Rundqvist S, Bang A, Aune S, Lundstrom G, Ekstrom L, et al. Is there a difference between women and men in characteristics and outcome after in hospital cardiac arrest?. Resuscitation. Apr 2001;49(1):15-23. [Medline].

  16. Hoffman JR, Stevenson LW. Postdefibrillation idioventricular rhythm--a salvageable condition. West J Med. Feb 1987;146(2):188-91. [Medline].

  17. Kim C, Fahrenbruch CE, Cobb LA, Eisenberg MS. Out-of-hospital cardiac arrest in men and women. Circulation. Nov 27 2001;104(22):2699-703. [Medline].

  18. Paradis NA, Martin GB, Goetting MG. Aortic pressure during human cardiac arrest. Identification of pseudo- electromechanical dissociation. Chest. Jan 1992;101(1):123-8. [Medline].

  19. Parish DC, Dinesh Chandra KM, Dane FC. Success changes the problem: why ventricular fibrillation is declining, why pulseless electrical activity is emerging, and what to do about it. Resuscitation. Jul 2003;58(1):31-5. [Medline].

  20. Stueven HA, Aufderheide T, Waite EM. Electromechanical dissociation: six years prehospital experience. Resuscitation. Apr 1989;17(2):173-82. [Medline].

  21. Vincent JL, Thijs L, Weil MH. Clinical and experimental studies on electromechanical dissociation. Circulation. Jul 1981;64(1):18-27. [Medline].

  22. Warner LL, Hoffman JR, Baraff LJ. Prognostic significance of field response in out-of-hospital ventricular fibrillation. Chest. Jan 1985;87(1):22-8. [Medline].

  23. Youngquist ST, Kaji AH, Niemann JT. Beta-blocker use and the changing epidemiology of out-of-hospital cardiac arrest rhythms. Resuscitation. Mar 2008;76(3):376-80. [Medline].

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Further Reading

Clinical guidelines

(1) ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to revise the 1999 guidelines for the Management of Acute Myocardial Infarction). (2) 2007 focused update of the ACC/AHA 2004 guidelines for the management of patients with ST-elevation myocardial infarction. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
American College of Cardiology Foundation - Medical Specialty Society
American Heart Association - Professional Association.  1996 Nov 1 (revised 2004 Jul; addendum released 2008 Jan).  Original guideline: 211 pages; Focused update: 38.  NGC:006289

Cardiac arrhythmias in coronary heart disease. A national clinical guideline.
Scottish Intercollegiate Guidelines Network - National Government Agency [Non-U.S.].  2007 Feb.  40 pages.  NGC:005528
 
ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. A report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death).
American College of Cardiology Foundation - Medical Specialty Society
American Heart Association - Professional Association
European Heart Rhythm Association - Professional Association
European Society of Cardiology - Medical Specialty Society
Heart Rhythm Society - Professional Association.  2006 Sep 5.  100 pages.  NGC:005208

Resuscitation and defibrillation in the health care setting — 2004 revision & update.
American Association for Respiratory Care - Professional Association.  1993 Dec (revised 2004 Sep).  15 pages.  NGC:004081

Clinical trials

 SmartCPR Trial: An Analysis of a Waveform-Based Automated External Defibrillation (AED) Algorithm on Survival From Out-of-Hospital Ventricular Fibrillation

Pre-Shock Cardiopulmonary Resuscitation to Patients With Out-of-Hospital Resuscitation, A Randomised Clinical Trial

Efficacy of Methylprednisolone for Hantavirus Cardiopulmonary Syndrome

Related eMedicine topics

 Asystole (Emergency Medicine)

Ventricular Fibrillation (Cardiology)

Ventricular Fibrillation (Emergency Medicine)

Ventricular Fibrillation (Pediatrics)

Cardiopulmonary Resuscitation (CPR) (Procedures)

Therapeutic Hypothermia (Procedures)

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Keywords

pulseless electrical activity, electromechanical dissociation, cardiopulmonary resuscitation, CPR, advanced cardiac life support, ACLS, cardia arrest, treatment, symptoms, cardiac arrhythmia, cardiac contractions, ventricular mechanical activity, ventricular electrical activity, EMD, PEA, pseudo-PEA

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Contributor Information and Disclosures

Author

Patrick O'Beirne, MD, Fellow in Cardiovascular Medicine, UMass Memorial Medical Center
Patrick O'Beirne, MD is a member of the following medical societies: American College of Cardiology, American Medical Association, Massachusetts Medical Society, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Coauthor(s)

Dionyssios A Robotis, MD, MPH, FACC, Assistant Professor of Medicine, University of Massachusetts; Consulting Staff Cardiologist/Electrophysiologist, University of Massachusetts Memorial Medical Center
Dionyssios A Robotis, MD, MPH, FACC is a member of the following medical societies: American College of Cardiology, Cardiac Electrophysiology Society, Heart Rhythm Society, and Massachusetts Medical Society
Disclosure: Nothing to disclose.

Lawrence Rosenthal, MD, PhD, Associate Professor of Medicine, Director, Section of Cardiac Electrophysiology and Pacing, Fellowship Director of Clinical Cardiac Electrophysiology, Department of Internal Medicine, Division of Cardiovascular Medicine, University of Massachusetts Memorial Medical Center
Lawrence Rosenthal, MD, PhD is a member of the following medical societies: American College of Cardiology, American Heart Association, Heart Rhythm Society, and Massachusetts Medical Society
Disclosure: Nothing to disclose.

Medical Editor

Eric Vanderbush, MD, FACC, MD, Chief, Department of Internal Medicine, Division of Cardiology, Clinical Assistant Professor, Harlem Hospital Center and Columbia University
Eric Vanderbush, MD, FACC, MD is a member of the following medical societies: American College of Cardiology and American Heart Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Steven J Compton, MD, FACC, FACP, Director of Cardiac Electrophysiology, Alaska Heart Institute, Providence and Alaska Regional Hospitals
Steven J Compton, MD, FACC, FACP is a member of the following medical societies: Alaska State Medical Association, American College of Cardiology, American College of Physicians, and Heart Rhythm Society
Disclosure: Nothing to disclose.

CME Editor

Amer Suleman, MD, Consultant in Electrophysiology and Cardiovascular Medicine, Department of Internal Medicine, Division of Cardiology, Medical City Dallas Hospital
Amer Suleman, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Institute of Stress, American Society of Hypertension, Federation of American Societies for Experimental Biology, Royal Society of Medicine, and Society of Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

Chief Editor

Jeffrey N Rottman, MD, Professor of Medicine and Pharmacology, Director, Clinical Cardiac Electrophysiology Fellowship Program, Vanderbilt University School of Medicine; Chief, Department of Cardiology, Nashville Veterans Affairs Medical Center
Jeffrey N Rottman, MD is a member of the following medical societies: American Heart Association and North American Society of Pacing and Electrophysiology (NASPE)
Disclosure: Nothing to disclose.

 
 
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