Pulseless Electrical Activity Treatment & Management

For a patient in whom PEA is suspected, the American Heart Association-Advanced Cardiac Life Support (AHA-ACLS) guidelines protocol (revised in 2010^{[13, 14]} ) recommends the following:^[15]

• Initiate CPR
• 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:

• Hypovolemia
• Hypoxia
• Acidosis
• Hypokalemia/hyperkalemia
• Hypoglycemia
• Hypothermia
• Toxins (eg, tricyclic antidepressants, digoxin, calcium channel blocker, beta-blockers)
• Cardiac tamponade
• Tension pneumothorax
• 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.

Consultations

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.

Transfer

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.

Prevention

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.^{[16, 17]}

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).