Approach Considerations
Once reversible causes of pulseless electrical activity (PEA) are identified, they should be corrected immediately. This process may involve needle decompression of pneumothorax, pericardiocentesis for tamponade, volume infusion, correction of body temperature, administration of thrombolytics, or surgical embolectomy for pulmonary embolus.
Consultations
Once the cause of 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 restoration of hemodynamic stability.
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 PEA:
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Patients who have been on prolonged bed rest should receive deep venous thrombosis (DVT) prophylaxis.
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Patients who are on ventilators should be monitored carefully for the development of auto–positive-end-expiratory pressure (PEEP).
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Hypovolemia should be treated aggressively, especially in patients with active bleeding.
Pharmacologic Therapy
Resuscitative pharmacology includes epinephrine and atropine. [27] Epinephrine should be administered in 1-mg doses intravenously/intraosseously (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 or calcium channel blockers, may benefit from higher-dose epinephrine.
If the underlying rhythm is bradycardia (ie, heart rate < 60 bpm) associated with hypotension, then atropine (1 mg IV q3-5 min, up to three 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—therefore, this sign cannot then 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 of sodium bicarbonate is discouraged, because it worsens intracellular and intracerebral acidosis and does not appear to alter the mortality rate.
Surgical Care
Pericardiocentesis and emergent cardiac surgery may be lifesaving procedures in appropriate patients with pulseless electrical activity (PEA). 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 the availability of expertise and support services. Patient selection is paramount because cardiopulmonary bypass 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 PEA, or a profound low-output state, may also be addressed with different means of circulatory assist (eg, intraaortic balloon pump, extracorporeal membrane oxygenation, [28] cardiopulmonary bypass, ventricular assist device).
