Pulseless Electrical Activity Clinical Presentation: History and Physical Examination

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Presentation

History and Physical Examination

Knowledge of prior medical conditions allows prompt identification and correction of reversible causes. For example, a debilitated patient who develops acute respiratory failure and then manifests pulseless electrical activity (PEA) may have a pulmonary embolus. If an elderly woman develops PEA 2-5 days after a myocardial infarction, a cardiac etiology should be considered (ie, cardiac rupture, recurrent infarction). History of prior drug intake is crucial, enabling prompt treatment of patients in whom drug overdose is suspected. The presence of PEA in the setting of trauma makes hemorrhage (hypovolemia), tension pneumothorax, and cardiac tamponade the more likely causes.

By definition, patients with pulseless electrical activity (PEA) have no pulse in the presence of organized electrical activity. The physical examination should focus on identification of reversible causes; for example, tracheal shift or the unilateral absence of breath sounds indicates tension pneumothorax, while normal lung sounds and distended jugular veins point to cardiac tamponade.

Differential Diagnoses

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].

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Author

Sandy N Shah, DO, MBA, FACC, FACP, FACOI Cardiologist

Sandy N Shah, DO, MBA, FACC, FACP, FACOI is a member of the following medical societies: American College of Cardiology, American College of Osteopathic Internists, American College of Physicians, American Medical Association, American Osteopathic Association, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions

Disclosure: Nothing to disclose.

Coauthor(s)

Arti N Shah, MD, MS, FACC, FACP, CEPS-AC, CEDS Assistant Professor of Medicine, Mount Sinai School of Medicine; Director of Electrophysiology, Elmhurst Hospital Center and Queens Hospital Center

Arti N Shah, MD, MS, FACC, FACP, CEPS-AC, CEDS is a member of the following medical societies: American Association of Cardiologists of Indian Origin, American College of Cardiology, American College of Physicians, American Heart Association, Cardiac Electrophysiology Society, European Heart Rhythm Society, European Society of Cardiology, Heart Rhythm Society, New York Academy of Medicine

Disclosure: Nothing to disclose.

Chief Editor

Jeffrey N Rottman, MD Professor of Medicine, Department of Medicine, Division of Cardiovascular Medicine, University of Maryland School of Medicine; Cardiologist/Electrophysiologist, University of Maryland Medical System and VA Maryland Health Care System

Jeffrey N Rottman, MD is a member of the following medical societies: American Heart Association, Heart Rhythm Society

Disclosure: Nothing to disclose.

Acknowledgements

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