Levophed (Norepinephrine) in Pulseless Electrical Activity (PEA)
Levophed (norepinephrine) is not recommended for routine use in pulseless electrical activity (PEA) cardiac arrest. The American Heart Association guidelines specifically recommend epinephrine as the primary vasopressor for PEA, with no recommendation for norepinephrine in this setting 1, 2.
Standard Management of PEA
- High-quality CPR with minimal interruptions in chest compressions is the foundation of PEA management 2
- Epinephrine 1 mg IV/IO should be administered every 3-5 minutes during cardiac arrest resuscitation 3, 2
- Identification and treatment of potentially reversible causes is crucial for improving outcomes in PEA 2
- Atropine and transcutaneous pacing should be considered if asystole and/or PEA are present, particularly in anaphylaxis-related cardiac arrest 1
Vasopressors in Cardiac Arrest
- Epinephrine is the primary vasopressor recommended for all forms of cardiac arrest including PEA 1, 3
- While vasopressors may improve return of spontaneous circulation (ROSC) and short-term survival, there is insufficient evidence that they improve survival to discharge or neurological outcomes 1
- For PEA specifically, the American Heart Association recommends epinephrine 0.01 mg/kg every 3-5 minutes while CPR continues 2
- There is no specific recommendation for norepinephrine (Levophed) use in the PEA cardiac arrest algorithm 1
Special Considerations
- For hypotension that is refractory to volume replacement and epinephrine injections (not in cardiac arrest), dopamine can be considered as a vasopressor infusion 1
- In anaphylaxis-related cardiac arrest with PEA, high-dose epinephrine administration is recommended, with potential consideration of higher subsequent dosages (0.1-0.2 mg/kg) for unresponsive PEA 1
- Prolonged resuscitation efforts are encouraged in PEA, as they are more likely to be successful, particularly when the patient is young with a healthy cardiovascular system 1, 4
Underlying Causes of PEA
- PEA is often caused by reversible conditions that should be identified and treated promptly 2, 5
- The "H's and T's" should be considered: Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hypo/hyperkalemia, Hypothermia, Toxins, Tamponade (cardiac), Tension pneumothorax, Thrombosis (coronary or pulmonary) 2
- For suspected pulmonary embolism causing PEA, thrombolysis may be considered, with studies showing improved outcomes with early administration 2, 6
Common Pitfalls
- Failing to identify and treat the underlying cause of PEA, which is essential for successful resuscitation 2, 5
- Not recognizing that different presentations of PEA (primary vs. secondary after other rhythms) may have different probabilities of achieving ROSC 4
- Using high-dose epinephrine routinely without specific indications 3
- Premature termination of resuscitation efforts in PEA, when continued efforts may be beneficial 1, 4
In summary, while vasopressors are used in cardiac arrest management, current guidelines specifically recommend epinephrine for PEA, with no recommendation for routine use of norepinephrine (Levophed) in this setting.