Pulseless Electrical Activity (PEA)

Section 4 - CARDIAC

4.04 PULSELESS ELECTRICAL ACTIVITY (PEA)

Pulseless Electrical Activity is a condition associated with poor outcomes. It is identified by the presence of cardiac electrical activity with no corresponding mechanical pulse or signs of perfusion. It is important to CONFIRM true PEA early in the management of the case. Consider all possible reversible causes for PEA utilizing a national recommended mnemonic of “H’s and T’s”:

H’s	T’s
Hypovolemia	Tension Pneumothorax
Hypoxia	Tamponade, cardiac
Hydrogen Ion (acidosis)	Toxins or Tablets (overdose)
Hypo/hyperkalemia	Thrombosis, pulmonary
Hypothermia	Thrombosis, cardiac

In addition, also consider the following:

Hypoglycemia

Trauma

BASED ON THE MEDICAL ETIOLOGY OF PEA REFER TO APPROPRIATE PRACTICE PARAMETER:

• Hypovolemia, SHOCK (5.13).
• Tension Pneumothorax, CHEST INJURIES (6.04).
• Hypoxia / Acidosis, INITIAL MEDICAL CARE (2.01).
• Hypothermia, COLD EMERGENCIES (5.06).
• Hypoglycemia, HYPO/HYPERGLYCEMIA (5.10)
• Toxins, DRUG OVERDOSE/POISONING (5.05)

When the Patient found in True PEA:

• Initiate 5 cycles of high quality CPR (push hard/push fast)
  • Minimum of 100 compressions per minute, minimize interruptions
  • Compression rate of 30:2 for approximately 2 minutes
  • Depth of compression of at least 2 inches
  • Initiate the use of a mechanical compression device if available
• Assist ventilations with OXYGEN @ 100% via BVM - DO NOT HYPERVENTILATE
• Establish intravenous access via IV or IO
• Reassess for circulation every two minutes
  • If a shockable rhythm is identified proceed to VF/VT PARAMETER (4.08)
• Consider advanced airway procedure using supraglottic airway (king tube) or endotracheal intubation
  • Do not interrupt compressions to place an advanced airway
  • Confirm tube placement with capnography (a range 5-20 mmHg is indicative of low cardiac output)
• If hypovolemia suspected, administer IV fluid bolus 200 - 300 ml and reassess
• If HYPOTHERMIC, also follow HYPOTHERMIC PARAMETER (5.06)

Pharmacologic Therapy:

• EPINEPHRINE 1:10,000 1 mg IV / IO – repeat every 3-5 minutes of arrest

OR

• VASOPRESSIN 40 units IV / IO – to replace the first or second dose of epinephrine
  • Vasopressin is a one-time dose

The current national guidelines do not include ATROPINE from treatment of TRUE PEA as there is no proof it has a therapeutic benefit. Under the Seminole County Practice Parameters the use of ATROPINE SULFATE is indicated in cardiac arrest that may be caused by extreme bradycardia/hypotension.

Check for pulse and rhythm change after all interventions.

Cases of suspected bradycardia, relative bradycardia or vagally stimulated such as patients found in the restroom.

• First, ATROPINE 0.5 -1.0 mg rapid IVP. Repeat every 3 - 5 minutes up to a total of 0.04 mg/kg or approximately 3 mg
• Apply TCP, set at maximum Milliamp. If pulse generated, decrease dosage to setting which still maintains a palpable pulse. If unsuccessful, reattempt capture every 3 - 5 minutes as above
• EPINEPHRINE 1:10,000 1 mg IVP or IO Repeat EPINEPHRINE every 3 - 5 minutes of continued arrest

If patient combative post resuscitation, refer to ANALGESIA /SEDATION PARAMETER (2.04).