From the Guidelines
To treat PEA (Pulseless Electrical Activity) arrest, immediately begin high-quality CPR with chest compressions at a rate of 100-120 compressions per minute and a depth of 2-2.4 inches, and administer epinephrine 1 mg IV/IO every 3-5 minutes throughout the resuscitation, as recommended by the 2022 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations 1.
Key Components of PEA Arrest Treatment
- High-quality CPR with minimal interruptions
- Epinephrine administration every 3-5 minutes
- Identification and treatment of potential underlying causes using the "H's and T's" framework:
- Hypoxia (provide oxygen)
- Hypovolemia (give IV fluids)
- Hydrogen ion (acidosis)
- Hypo/Hyperkalemia (give calcium chloride 1g IV for hyperkalemia)
- Hypothermia (active rewarming)
- Tension pneumothorax (needle decompression)
- Tamponade (pericardiocentesis)
- Toxins (specific antidotes)
- Thrombosis (pulmonary or coronary - consider thrombolytics)
Additional Considerations
- Secure the airway as needed, but prioritize uninterrupted chest compressions
- Reassess rhythm every 2 minutes while continuing CPR
- Consider advanced treatment options, such as systemic thrombolysis, surgical or percutaneous mechanical embolectomy, and ECPR, for patients with fulminant PE 1
- PEA has a better prognosis than asystole if the underlying cause can be rapidly identified and corrected, as it indicates the heart has electrical activity but inadequate mechanical function to generate a pulse 1
From the Research
Treatment of PEA Arrest
- PEA is a crossroad in which the subsequent course is determined, and the four distinct presentations of PEA behave differently on important characteristics 2
- A transition to PEA during resuscitation should encourage the resuscitation team to continue resuscitative efforts 2
- The use of cardiopulmonary resuscitation with ECMO support (ECPR) has shown to improve outcome in patients after cardiac arrest under resuscitation, and patients with PEA should be carefully considered for ECPR 3
- Survival to discharge in patients with PEA as initial rhythm at the time of decision for ECPR is 23.8%, and all survivors to discharge had a good neurological outcome 3
Long-term Outcome
- The long-term outcome of patients successfully resuscitated from pre-hospital cardiac arrest with initial PEA is unknown, but studies suggest that half of those who survive to hospital discharge are still alive after 5 years 4
- Patients with initial PEA who survive to hospital discharge have a good self-assessed quality of life with only mild to moderate impairments in activities of daily life 4
- Five of the seven patients alive one year after resuscitation presented with the same functional level as prior to cardiac arrest 4
Resuscitation Efforts
- During resuscitation, ECG, chest compressions, and ventilations should be recorded by defibrillators, and each event should be manually annotated using a graphical application 2
- Time average transition intensities to ROSC from primary PEA and secondary PEA after ASY were 0.1 per min, peaking at 4 and 7 minutes, respectively 2
- Much higher transition intensities to ROSC, average of 0.15 per min, were observed for secondary PEA after VF/VT or after ROSC 2