Pulseless Electrical Activity Treatment & Management
- Author: Sandy N Shah, DO, MBA, FACC, FACP, FACOI; Chief Editor: Jeffrey N Rottman, MD more...
Place an intravenous line
Intubate the patient
Correct hypoxia by administering 100% oxygen
Once these basic measures are in place, reversible causes should be sought and corrected. These include the following:
Toxins (eg, tricyclic antidepressants, digoxin, calcium channel blocker, beta-blockers)
Massive pulmonary embolus
Acute myocardial infarction
Once reversible causes are identified, they should be corrected immediately. This process involves needle decompression of pneumothorax, pericardiocentesis for tamponade, volume infusion, correction of body temperature, and administration of thrombolytics or surgical embolectomy for pulmonary embolus.
Once the cause of pulseless electrical activity (PEA) is identified and the patient's condition is stabilized, consultation with appropriate services may be obtained. A cardiothoracic surgery consult may be appropriate for a pulmonary embolectomy in patients with a large pulmonary embolus. In patients with drug overdose, consultation with the toxicology department or the local poison center may be useful after hemodynamic stability is restored.
Some institutions may not have the capability to provide specialized care (eg, cardiac surgery, pulmonary embolectomy). Once stabilized, patients in these centers may be transferred to tertiary care centers for definitive care.
The following measures may prevent some cases of in-hospital pulseless electrical activity:
Patients who have been on prolonged bed rest - Should receive deep venous thrombosis (DVT) prophylaxis
Patients who are on ventilators - Should be monitored carefully for auto-PEEP development
Hypovolemia - Should be treated aggressively, especially in patients with active bleeding
Resuscitative pharmacology includes epinephrine, vasopressin, and atropine. Epinephrine should be administered in 1 mg doses IV/IO every 3-5 minutes during pulseless electrical activity (PEA) arrest. Higher doses of epinephrine have been studied and show no improvement in survival or neurologic outcomes in most patients. Special populations of patients, such as those who have overdosed on beta blockers and calcium channel blockers, may benefit from higher-dose epinephrine. Vasopressin 40 U IV/IO may replace either the first or second dose of epinephrine in patients with PEA.[21, 22]
If the underlying rhythm is bradycardia (ie, heart rate < 60 bpm) associated with hypotension, then atropine (1 mg IV q3-5min, up to 3 doses) should be administered. This is considered the total vagolytic dose, beyond which no further benefit will occur. Note that atropine may cause pupillary dilation, and this sign then cannot be used to assess neurologic function.
Sodium bicarbonate may be administered only in patients with severe, systemic acidosis, hyperkalemia, or a tricyclic antidepressant overdose. The dose is 1 mEq/kg. Routine administration is discouraged because it worsens intracellular and intracerebral acidosis and does not appear to alter the mortality rate.
Pericardiocentesis and emergent cardiac surgery may be lifesaving procedures in appropriate patients. In refractory cases, if the patient has suffered chest trauma, a thoracotomy may be performed, provided adequate expertise is available.
Prompt initiation of a cardiopulmonary bypass may have a role in carefully selected patients. This maneuver requires availability of expertise and support services. Patient selection is paramount because it should be used only in patients who have an easily reversible etiology of cardiac dysfunction. In an animal model, initiation of prompt cardiopulmonary bypass resulted in a higher rate of success in returning circulation than administration of high- or standard-dose epinephrine. Cardiac pacing can result in electrical capture but does not necessarily increase the incidence of mechanical contractions; hence, this procedure is not recommended.
Near pulseless electrical activity (PEA), or a profound low output state, may also be addressed with different means of circulatory assist (eg, intra-aortic balloon pump, extracorporeal membrane oxygenation, cardiopulmonary bypass, ventricular assist device).
Teodorescu C, Reinier K, Uy-Evanado A, et al. Antipsychotic drugs are associated with pulseless electrical activity: the Oregon Sudden Unexpected Death Study. Heart Rhythm. 2013 Apr. 10(4):526-30. [Medline].
Littmann L, Bustin DJ, Haley MW. A simplified and structured teaching tool for the evaluation and management of pulseless electrical activity. Med Princ Pract. 2014. 23(1):1-6. [Medline].
Desbiens NA. Simplifying the diagnosis and management of pulseless electrical activity in adults: a qualitative review. Crit Care Med. 2008 Feb. 36(2):391-6. [Medline].
Hutchings AC, Darcy KJ, Cumberbatch GL. Tension pneumothorax secondary to automatic mechanical compression decompression device. Emerg Med J. 2009 Feb. 26(2):145-6. [Medline].
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. 2009 Apr. 16(2):103-5. [Medline].
Fuzaylov G, Woods B, Driscoll W. Documentation of resuscitation of an infant with pulseless electrical activity because of venous air embolism. Paediatr Anaesth. 2008 Nov. 18(11):1121-3. [Medline].
Youngquist ST, Kaji AH, Niemann JT. Beta-blocker use and the changing epidemiology of out-of-hospital cardiac arrest rhythms. Resuscitation. 2008 Mar. 76(3):376-80. [Medline].
Raizes G, Wagner GS, Hackel DB. Instantaneous nonarrhythmic cardiac death in acute myocardial infarction. Am J Cardiol. 1977 Jan. 39(1):1-6. [Medline].
Nadkarni VM, Larkin GL, Peberdy MA, et al. First documented rhythm and clinical outcome from in-hospital cardiac arrest among children and adults. JAMA. 2006 Jan 4. 295(1):50-7. [Medline].
Meaney PA, Nadkarni VM, Kern KB, Indik JH, Halperin HR, Berg RA. Rhythms and outcomes of adult in-hospital cardiac arrest. Crit Care Med. 2010 Jan. 38(1):101-8. [Medline].
Hauck M, Studnek J, Heffner AC, Pearson DA. Cardiac arrest with initial arrest rhythm of pulseless electrical activity: do rhythm characteristics correlate with outcome?. Am J Emerg Med. 2015 Jul. 33 (7):891-4. [Medline].
Teodorescu C, Reinier K, Dervan C, et al. Factors associated with pulseless electric activity versus ventricular fibrillation: the Oregon sudden unexpected death study. Circulation. 2010 Nov 23. 122(21):2116-22. [Medline].
Nichols R, Zawada E. A case study in therapeutic hypothermia treatment post-cardiac arrest in a 56-year-old male. S D Med. 2008 Oct. 61(10):371-3. [Medline].
Do DH, Hayase J, Tiecher RD, Bai Y, Hu X, Boyle NG. ECG changes on continuous telemetry preceding in-hospital cardiac arrests. J Electrocardiol. 2015 Nov-Dec. 48 (6):1062-8. [Medline].
Hernandez C, Shuler K, Hannan H, Sonyika C, Likourezos A, Marshall J. C.A.U.S.E.: Cardiac arrest ultra-sound exam--a better approach to managing patients in primary non-arrhythmogenic cardiac arrest. Resuscitation. 2008 Feb. 76(2):198-206. [Medline].
Testa A, Cibinel GA, Portale G, Forte P, Giannuzzi R, Pignataro G. The proposal of an integrated ultrasonographic approach into the ALS algorithm for cardiac arrest: the PEA protocol. Eur Rev Med Pharmacol Sci. 2010 Feb. 14(2):77-88. [Medline].
Morrison LJ, Deakin CD, Morley PT, Callaway CW, Kerber RE, Kronick SL, et al. Part 8: advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2010 Oct 19. 122(16 Suppl 2):S345-421. [Medline].
Hazinski MF, Nolan JP, Billi JE et al. Part 1: executive summary: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2010 Oct 19. 122(16 Suppl 2):S250-75. [Medline].
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. 2005 Dec 13. 112(24 Suppl):IV206-11. [Medline].
Wagner BJ, Yunker NS. A Pharmacologic Review of Cardiac Arrest. Plast Surg Nurs. 2014 July/September. 34(3):133-138. [Medline].
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. 2009 Apr. 2(1):57-8. [Medline].
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. 2008 Dec. 1(4):311-6. [Medline].