UMEM Educational Pearls

Title: Pulseless Electrical Activity (PEA)

Posted: 2/27/2014 by Semhar Tewelde, MD (Emailed: 3/2/2014) (Updated: 3/2/2014)
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Pulseless Electrical Activity (PEA)

ACLS algorithm for PEA focuses on memorizing the “ H's & T's" without a systematic approach on how to evaluate & treat the possible etiologies

A modified approach to PEA focuses on “cause-specific” interventions utilizing two simple tools: ECG and Bedside Ultrasound (US)

Simplified PEA Algorithm

♦1st obtain the ECG and assess the QRS-complex length (narrow vs. wide)

♦ A narrow QRS-complex suggests a mechanical problem: RV inflow or outflow obstruction

Utilize bedside US to assess for RV collapsibility vs. dilation

A collapsed RV suggests tamponade, tension PTX or mechanical hyperinflation

A dilated RV suggests PE

The above listed etiologies all have a preserved/hyperdynamic LV Tx begins w/aggressive IVF’s followed by “cause-specific” therapy: pericardiocentesis, needle decompression, forced expiration/vent management, and thrombolysis respectively

♦ A wide QRS-complex suggests a metabolic (hyperK/acidosis/toxins), ischemic, or LV problem

Utilize bedside US to assess for LV hypokinesis/akinesis

For metabolic/toxic etiologies treat w/calcium chloride and sodium bicarbonate +/- vasopressors

For ischemia and LV failure treat w/cardiac cath. vs. thrombolysis +/- vasopressors/inotropes

♦Trauma and several other etiologies of PEA that are seldom forgotten in any critically ill patient (hypothermia, hypoxia, and hypoglycemia) are not included in this algorithm.

References

Littmann L, Bustin D, Haley M. A Simplified and Structured Teaching Tool for the Evaluation and Management of Pulseless Electrical Activity. Med Princ Pract 2014; 23:1-6