Pulseless electrical activity (PEA) is an organized electrical activity without a palpable pulse. 1/3 of cardiac arrest cases will be pulseless electrical activity and the overall prognosis of these patients is worse than patients who have shockable rhythms (ventricular fibrillation or pulseless ventricular tachycardia).
It can be a challenge to decide when to terminate or continue resuscitation efforts in PEA arrest. Palpating pulses is difficult in the setting of a code situation, neither sensitive nor specific based on current literature. The use of POCUS could help split PEA patients into Pseudo-PEA (cardiac activity on US = profound shock) vs True-PEA (no cardiac activity on…
Pseudo-PEA is different from PEA. Utilize POCUS during your cardiac arrests to identify it and to help diagnose reversible causes, and treat it as a profound shock state with the appropriate supportive measures, i.e. pressors or inotropy.
The way we learn to manage pulseless electrical activity (PEA) from the Advanced Cardiac Life Support course is a mockery wrapped up in a sham. The mnemonic is cumbersome and the treatment (such as CPR for all, empiric epinephrine) is not always appropriate for a patient with normal electrical activity and a pulse. Fear not, because there is a way out of this madness.
The H's and T's are of taught for Ddx of PEA... but...
They are difficult to remember.
They only apply if you work in an area that speaks English.
They are not perfect.
HYPOkalemia rarely causes PEA.
HYPOthermia is usually not a medical mystery.
We’re all aware of the poor prognosis of patients in cardiac arrest but three studies have shown increased rates of ROSC in patients with pseudo-PEA compared to true PEA.
The H’s and T’s proposed by the AHA is far too complex, unwieldy and based on little empiric evidence. The alternative strategy of using the QRS width to guide resuscitative efforts, though more straightforward, is based off an assumption that when empirically tested does not reliably predict causes or outcomes. Rather, a far simpler approach should be employed. Rather than using the EKG, which consistently fails to reliably differentiate these etiologies, the utilization of bedside ultrasound can quickly and accurately identify 4 of the 5 correctable causes.
The prognosis of patients with PEA is grim; not surprisingly, the list of associated clinical entities includes numerous malignant syndromes. Thus, the vast majority of patients who present with PEA will not experience a return of spontaneous perfusion or survival to hospital discharge.
Today, bedside ultrasound is a fundamental tool that is quick, safe, inexpensive and reproducible. Not only can it provide the physician with critical information on reversible causes of arrest, but it can also be used to predict survival. Of note is its utility in predicting worse survival outcomes in patients with cardiac standstill, i.e., no cardiac activity witnessed with ultrasound. Unfortunately, despite the increasing evidence surrounding ultrasound use in arrest, bedside ultrasound is still largely underutilized during the resuscitation process.
Both the European and American ACLS guidelines stress the importance of quickly finding and addressing the cause of PEA. This is traditionally done with recalling the 5 to 6 H’s and T’s, but during cardiopulmonary resuscitation it is difficult to recall all 13 causes of PEA by trying to recall this list.
we talk about a bunch of PEA stuff. Scott proposes 2 new terms to bring us into the modern era: PREM-pulseless with a rhythm and echocardiographic motion PRES-pulseless with a rhythm and echocardiographic standstill Joe asks why we shouldn’t just treat the latter like asystole, and he’s probably right. But what of the former? What should we do with that?
True PEA, once known as electro-mechanical dissociation is the presents of an organized electrical cardiac rhythm without cardiac muscle activity (cardiac standstill).
Pseudo-PEA is an organized electrical cardiac rhythm and it has cardiac muscle activity (found on POCUS echo) however, there may not be a palpable pulse due to profound shock.
We discuss the notion that the palpation technique is poor at determining whether or not a patient has a pulse, that the POCUS pulse is more accurate and as rapid, compared to the palpation technique, at determining whether or not a patient has a pulse, the difference between true PEA arrest, PseudoPEA and PREM, why epinephrine may be harmful in PEA,
Look at the monitor: is the QRS wide or narrow?
The use of POCUS could help split PEA patients into Pseudo-PEA (cardiac activity on US = profound shock) vs True-PEA (no cardiac activity on US) in determining the potential for ROSC.
Since the differential diagnosis for PEA is wide and ACLS offers little guidance, try these tips to improve the chances of patient survival.
In reality, pulseless electrical activity encompasses a very heterogeneous variety of severe circulatory shock states ranging in severity from pseudo-cardiac arrest to true electro-mechanical dissociation with cardiac standstill
Pulseless electrical activity does not necessarily mean the lack of mechanical activity. There can be ventricular contractions and detectable pressures in the aorta, which are also known as pseudo-PEA. True pulseless electrical activity is a state in which cardiac contractions are lacking in the presence of coordinated electrical impulses.