What is the management after Pulseless Electrical Activity (PEA) arrest?

From the Guidelines

Management after Pulseless Electrical Activity (PEA) arrest involves administering epinephrine as soon as feasible during CPR.

Key Considerations

• The administration of epinephrine during CPR for PEA is a strong recommendation with very low–certainty evidence 1.
• The use of fibrinolytic drugs, surgical embolectomy, or percutaneous mechanical thrombectomy may be considered if PE is the suspected or known cause of cardiac arrest, although this is a weak recommendation with very low–certainty evidence 1.
• Identifying and correcting reversible causes of PEA, such as hypoxemia, severe volume loss, or sepsis, is crucial during CPR 1.
• Advanced life support measures, including high-quality CPR, placement of an advanced airway, and administration of empirical IV/IO crystalloid or blood transfusion, may be necessary depending on the underlying cause of PEA 1.
• Bedside cardiac ultrasonography may be performed to diagnose PEA, identify potential causes, and differentiate a pseudo-PEA state with wall motion, although this is a suggestion with a Grade 2C recommendation 1.

Treatment Approach

• Epinephrine administration: Administer epinephrine as soon as feasible during CPR for PEA, with a dose of 1 mg IV/IO, repeated every 3-5 minutes as needed 1.
• Reversible cause identification and correction: Identify and correct reversible causes of PEA, such as hypoxemia, severe volume loss, or sepsis, during CPR 1.
• Advanced life support measures: Provide high-quality CPR, place an advanced airway, and administer empirical IV/IO crystalloid or blood transfusion as necessary, depending on the underlying cause of PEA 1.
• Fibrinolytic therapy: Consider fibrinolytic therapy if PE is the suspected or known cause of cardiac arrest, although this is a weak recommendation with very low–certainty evidence 1.

From the Research

Management of Pulseless Electrical Activity (PEA) Arrest

The management of PEA arrest involves a structured approach to identify and treat the underlying cause.

• A proposed algorithm based on the differentiation of the PEA rhythm into narrow- or wide-complex subcategories can simplify the working differential and initial treatment approach 2.
• Bedside ultrasound can quickly point towards the most likely cause of PEA and guide resuscitation 2.

Treatment Approaches

Different treatment approaches have been studied, including:

• Synchronized chest compressions, which have been shown to increase coronary perfusion pressure (CPP) more than unsynchronized compressions in a pseudo-PEA swine model 3.
• Thrombolytic therapy, which has been used to treat PEA due to pulmonary embolism, with a study showing that low-dose systemic thrombolysis with tissue plasminogen activator (tPA) can lead to restoration of spontaneous circulation and improved survival 4.
• Cardiopulmonary resuscitation with ECMO support (ECPR), which has been shown to improve outcome in patients after cardiac arrest under resuscitation, and may be considered for patients with PEA as initial rhythm 5.

Electrocardiographic Presentations

The electrocardiographic presentations of PEA can vary, and recognition of patients with a potential opportunity for successful resuscitation is important 6.

• Electrocardiographic findings can help identify the underlying cause of PEA and guide management.

Considerations for Resuscitation

Considerations for resuscitation include:

• The use of ECPR, which may be considered for patients with PEA as initial rhythm, with a study showing a survival to discharge rate of 23.8% in this group 5.
• The importance of rapid administration of thrombolytic therapy, such as tPA, in patients with PEA due to pulmonary embolism 4.