What to do in a Pulseless Electrical Activity (PEA) arrest?

Management of Pulseless Electrical Activity (PEA) Arrest

In a PEA arrest, immediately begin high-quality CPR with chest compressions while simultaneously identifying and treating potentially reversible causes, as this approach offers the best chance for survival. 1

Initial Management

• Confirm cardiac arrest: Check for absence of pulse and breathing (or only gasping)

• Begin high-quality CPR immediately:

  • Rate: 100-120 compressions/minute
  • Depth: At least 2 inches (5 cm) in adults
  • Allow complete chest recoil
  • Minimize interruptions in compressions
  • Avoid excessive ventilation 2

• Establish IV/IO access as soon as possible

• Administer epinephrine 1 mg IV/IO as soon as feasible, then repeat every 3-5 minutes during CPR 2, 1

• Apply cardiac monitor/defibrillator to confirm PEA rhythm

Identify and Treat Reversible Causes (H's and T's)

During each 2-minute CPR cycle, systematically consider and address these potential causes:

1. Hypovolemia: Administer IV/IO crystalloid fluids
2. Hypoxia: Ensure proper oxygenation and ventilation
3. Hydrogen ion (acidosis): Ensure adequate ventilation
4. Hypo/Hyperkalemia: Consider calcium, insulin/glucose, sodium bicarbonate for hyperkalemia
5. Hypothermia: Active rewarming
6. Tension pneumothorax: Perform needle decompression if suspected
7. Tamponade, cardiac: Consider pericardiocentesis if suspected
8. Toxins: Administer specific antidotes if applicable
9. Thrombosis, pulmonary: Consider empiric fibrinolytic therapy for suspected pulmonary embolism 2, 3
10. Thrombosis, coronary: Consider emergent coronary intervention 2, 1

Advanced Airway Management

• Consider advanced airway placement after initial CPR cycles
• Use the most experienced provider for intubation
• Confirm placement with waveform capnography
• After advanced airway placement, provide 1 breath every 6 seconds (10 breaths/min) with continuous chest compressions 2

Diagnostic Tools During Resuscitation

• Capnography: If available, use to monitor CPR quality and detect ROSC (sudden increase in ETCO2 suggests improved cardiac output) 2, 1
• Point-of-care ultrasound: Consider during pulse checks to identify:
  • Cardiac tamponade
  • Right ventricular dilation (suggesting PE)
  • Severe hypovolemia
  • Presence of organized vs. disorganized cardiac activity 4

Special Considerations

• For suspected pulmonary embolism with PEA, consider fibrinolytic therapy (50 mg tPA as IV push) as this has shown significant improvement in survival 3
• Patients with organized cardiac activity on ultrasound may benefit from continuous adrenergic agents rather than bolus epinephrine 4
• Mechanical chest compression devices can provide consistent, high-quality compressions, particularly during transport or procedures 5

Post-ROSC Care

If ROSC is achieved:

• Immediately initiate post-cardiac arrest care
• Focus on treating hypoxemia and hypotension
• Diagnose and treat the underlying cause
• Consider therapeutic hypothermia for comatose patients 2

Common Pitfalls to Avoid

• Interrupting chest compressions for more than 10 seconds during pulse checks
• Failing to systematically consider all reversible causes
• Premature termination of resuscitation (PEA can transition to ROSC, particularly secondary PEA) 6
• Delaying epinephrine administration
• Focusing solely on medications without addressing underlying causes

Remember that PEA often has a treatable cause, and survival rates improve significantly when the underlying condition is identified and corrected promptly.