Pulseless Electrical Activity Workup

  • Author: Sandy N Shah, DO, MBA, FACC, FACOI; Chief Editor: Jeffrey N Rottman, MD   more...
 
Updated: Dec 16, 2011
 

Approach Considerations

The clinical scenario usually provides useful information. For example, in a previously intubated patient, tension pneumothorax and auto ̶ positive end-expiratory pressure (PEEP) are more likely to occur, while in a patient with prior myocardial infarction or congestive heart failure (CHF), myocardial dysfunction is likely. In a patient on dialysis, consider hyperkalemia.

A core temperature should always be obtained if the patient is thought to have hypothermia. In patients diagnosed with hypothermia, resuscitative efforts should be continued at least until the patient is rewarmed, because patient survival is possible even after prolonged resuscitation.[10]

Measure QRS duration, since it has prognostic significance. Patients with QRS duration of less than 0.2 second are more likely to recover, and high-dose epinephrine may be administered. Acute rightward axis shifts can suggest possible pulmonary embolus.

Because of the emergent nature of the problem, lab tests are not likely to be helpful in the immediate management of a patient with pulseless electrical activity (PEA). If available rapidly, however, values for arterial blood gases (ABGs) and serum electrolytes may provide information regarding serum pH, oxygenation, and serum potassium. Glucose evaluation can also be useful.

Invasive monitoring (eg, arterial line) may be placed if it does not cause a delay in delivering standard ACLS care. 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.

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.

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Echocardiography

Bedside echocardiography may rapidly identify reversible cardiac problems (eg, cardiac tamponade, tension pneumothorax, massive myocardial infarction, severe hypovolemia).[3, 11] The protocol proposed by Testa et al uses the acronym PEA, in reference to pulmonary, epigastric, and abdominal scans used to assess for causes of pulseless electrical activity (PEA).[12]

Echocardiography also identifies patients with weak cardiac contractions who have pseudo-PEA. This group of patients is more likely to benefit from aggressive resuscitation.[3] Patients with pseudo-PEA may have a rapidly reversible cause (eg, auto-PEEP, hypovolemia).

Echocardiography is also invaluable in identifying right ventricular enlargement, pulmonary hypertension suggestive of pulmonary emboli, cardiorrhexis, and ventricular septal rupture.

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Contributor Information and Disclosures
Author

Sandy N Shah, DO, MBA, FACC, FACOI,  Cardiologist, Houston, Texas

Sandy N Shah, DO, MBA, FACC, FACOI, is a member of the following medical societies: American College of Cardiology, American College of Osteopathic Internists, and American Osteopathic Association

Disclosure: Nothing to disclose.

Coauthor(s)

Patrick O'Beirne, MD  Fellow in Cardiovascular Medicine, University of Massachusetts 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.

Dionyssios A Robotis, MD, MPH, FACC  Clinical Associate Professor of Medicine, University of Massachusetts Medical School; 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, FACC, FHRS  Associate Professor of Medicine, Director, Section of Cardiac Pacing and Electrophysiology, Director of EP Fellowship Program, Division of Cardiovascular Disease, University of Massachusetts Memorial Medical Center

Lawrence Rosenthal, MD, PhD, FACC, FHRS is a member of the following medical societies: American College of Cardiology, American Heart Association, and Massachusetts Medical Society

Disclosure: Nothing to disclose.

Chief Editor

Jeffrey N Rottman, MD  Professor of Medicine and Pharmacology, 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.

Additional Contributors

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, American Heart Association, American Medical Association, and Heart Rhythm Society

Disclosure: Nothing to disclose.

David S Marks, MD Director of Cardiac Catheterization Laboratory, Froedtert Memorial Lutheran Hospital; Associate Professor, Department of Internal Medicine, Section of Cardiology, Medical College of Wisconsin

David S Marks, MD is a member of the following medical societies: American College of Cardiology, American Heart Association, American Medical Association, Medical Association of Georgia, and Society for Cardiac Angiography and Interventions

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Eric Vanderbush, MD, FACC Chief, Department of Internal Medicine, Division of Cardiology, Harlem Hospital Center; Clinical Assistant Professor of Cardiology, Columbia University College of Physicians and Surgeons

Eric Vanderbush, MD, FACC is a member of the following medical societies: American College of Cardiology and American Heart Association

Disclosure: Nothing to disclose.

Sumit Verma, MD, FACC Staff Electrophysiologist, Cardiology Consultants, Pensacola Heart Institute

Sumit Verma, MD, FACC is a member of the following medical societies: American College of Cardiology

Disclosure: Nothing to disclose.

References

  1. 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].

  2. 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].

  3. 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].

  4. 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].

  5. 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].

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

  7. 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].

  8. Meaney PA, Nadkarni VM, Kern KB, Indik JH, Halperin HR, Berg RA. Rhythms and outcomes of adult in-hospital cardiac arrest. Crit Care Med. Jan 2010;38(1):101-8. [Medline].

  9. Teodorescu C, Reinier K, Dervan C, et al. Factors associated with pulseless electric activity versus ventricular fibrillation: the Oregon sudden unexpected death study. Circulation. Nov 23 2010;122(21):2116-22. [Medline].

  10. 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].

  11. 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. Feb 2008;76(2):198-206. [Medline].

  12. 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. Feb 2010;14(2):77-88. [Medline].

  13. 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. Oct 19 2010;122(16 Suppl 2):S345-421. [Medline].

  14. 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. Oct 19 2010;122(16 Suppl 2):S250-75. [Medline].

  15. 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].

  16. 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].

  17. 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].

 
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