UMEM Educational Pearls

Title: PEA ... or is it?

Keywords: OHCA, cardiac arrest, resuscitation, PEA, pesudo-PEA, pulseless electrical activity (PubMed Search)

Posted: 11/12/2019 by Kami Windsor, MD
Click here to contact Kami Windsor, MD

When managing cardiac arrest, it is important to differentiate PEA, the presence of organized electrical activity without a pulse, from "pseudo-PEA,"where there is no pulse but there IS cardiac activity visualized on ultrasound.

Why:

Pseudo-PEA is essentially a profound, low-flow shock state that often has reversible causes, such as hypovolemia, massive PE, tension pneumothorax, etcetera.
Compared to PEA, with appropriate care patients with pseudo-PEA have a higher rate of ROSC as well as overall survival.

How:

POCUS during rhythm check in cardiac arrest. Be careful not to prolong the pause in compressions; acquire the US, if needed, for review once hands are back on the chest.

What:

In addition to searching for & addressing reversible causes of the pseudo-PEA, manage the profound shock state with pressors and/or inotropic support.
In EDs where TEE is utilized during cardiac arrest resuscitations, strongly consider synchronization of external compressions with intrinsic cardiac activity to potentially improve ventricular filling and therefore coronary perfusion pressure.

Bottom Line: 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.

References

Rabjohns J, Quan T, Boniface K, Pourmand A. Pseudo-pulseless electrical activity in the emergency department, an evidence based approach. Am J Emerg Med. 2019. DOI:https://doi.org/10.1016/j.ajem.2019.158503