Pulseless electrical activity differential diagnosis: Difference between revisions

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{{Pulseless electrical activity}}
{{Pulseless electrical activity}}
{{CMG}}
{{CMG}},{{AE}} {{M.N}}


==Overview==
==Overview==
PEA should be differentiated from [[asystole]] and [[ventricular fibrillation]].
PEA(Pulseless electrical activity) should be differentiated from [[asystole]] and [[ventricular fibrillation]], [[Ventricular flutter]], [[Torsade de Pointes]], [[Asystole]] etc.


==Differentiating Pulseless Electrical Activity from Other Diseases==
==Differentiating Pulseless Electrical Activity from Other Diseases==
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*[[Long QT syndrome]]
*[[Long QT syndrome]]
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* Ventricular tachycardia originates from a ventricular focus.
*[[Ventricular tachycardia (patient information)|Ventricular tachycardia]] originates from a [[ventricular]] focus.
* Lasts more than 30 seconds.
* Lasts more than 30 seconds.
* [[Broad QRS complex]]es: rate of >90 BPM.
* [[Broad QRS complex]]es: rate of >90 BPM.
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! style="padding: 5px 5px; background: #DCDCDC; " align="left"| '''[[Ventricular fibrillation]]''' <ref name="pmid19252119">{{cite journal |vauthors=Koplan BA, Stevenson WG |title=Ventricular tachycardia and sudden cardiac death |journal=Mayo Clin. Proc. |volume=84 |issue=3 |pages=289–97 |date=March 2009 |pmid=19252119 |pmc=2664600 |doi=10.1016/S0025-6196(11)61149-X |url=}}</ref><ref name="pmid28222965">{{cite journal |vauthors=Maury P, Sacher F, Rollin A, Mondoly P, Duparc A, Zeppenfeld K, Hascoet S |title=Ventricular arrhythmias and sudden death in tetralogy of Fallot |journal=Arch Cardiovasc Dis |volume=110 |issue=5 |pages=354–362 |date=May 2017 |pmid=28222965 |doi=10.1016/j.acvd.2016.12.006 |url=}}</ref><ref name="pmid1638716">{{cite journal |vauthors=Saumarez RC, Camm AJ, Panagos A, Gill JS, Stewart JT, de Belder MA, Simpson IA, McKenna WJ |title=Ventricular fibrillation in hypertrophic cardiomyopathy is associated with increased fractionation of paced right ventricular electrograms |journal=Circulation |volume=86 |issue=2 |pages=467–74 |date=August 1992 |pmid=1638716 |doi=10.1161/01.cir.86.2.467 |url=}}</ref><ref name="BektasSoyuncu2012">{{cite journal|last1=Bektas|first1=Firat|last2=Soyuncu|first2=Secgin|title=Hypokalemia-induced Ventricular Fibrillation|journal=The Journal of Emergency Medicine|volume=42|issue=2|year=2012|pages=184–185|issn=07364679|doi=10.1016/j.jemermed.2010.05.079}}</ref>
! style="padding: 5px 5px; background: #DCDCDC; " align="left"| '''[[Ventricular fibrillation]]''' <ref name="pmid19252119">{{cite journal |vauthors=Koplan BA, Stevenson WG |title=Ventricular tachycardia and sudden cardiac death |journal=Mayo Clin. Proc. |volume=84 |issue=3 |pages=289–97 |date=March 2009 |pmid=19252119 |pmc=2664600 |doi=10.1016/S0025-6196(11)61149-X |url=}}</ref><ref name="pmid28222965">{{cite journal |vauthors=Maury P, Sacher F, Rollin A, Mondoly P, Duparc A, Zeppenfeld K, Hascoet S |title=Ventricular arrhythmias and sudden death in tetralogy of Fallot |journal=Arch Cardiovasc Dis |volume=110 |issue=5 |pages=354–362 |date=May 2017 |pmid=28222965 |doi=10.1016/j.acvd.2016.12.006 |url=}}</ref><ref name="pmid1638716">{{cite journal |vauthors=Saumarez RC, Camm AJ, Panagos A, Gill JS, Stewart JT, de Belder MA, Simpson IA, McKenna WJ |title=Ventricular fibrillation in hypertrophic cardiomyopathy is associated with increased fractionation of paced right ventricular electrograms |journal=Circulation |volume=86 |issue=2 |pages=467–74 |date=August 1992 |pmid=1638716 |doi=10.1161/01.cir.86.2.467 |url=}}</ref><ref name="BektasSoyuncu2012">{{cite journal|last1=Bektas|first1=Firat|last2=Soyuncu|first2=Secgin|title=Hypokalemia-induced Ventricular Fibrillation|journal=The Journal of Emergency Medicine|volume=42|issue=2|year=2012|pages=184–185|issn=07364679|doi=10.1016/j.jemermed.2010.05.079}}</ref>
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*Acute coronary ischemia
*[[Coronary ischemia|Acute coronary ischemia]]
*[[cardiomyopathy|Cardiomyopathies]]
*[[cardiomyopathy|Cardiomyopathies]]
*[[Congenital heart disease]]
*[[Congenital heart disease]]
*[[Myocardial infarction]]
*[[Myocardial infarction]]
*[[Heart surgery]]
*[[Heart surgery]]
*Electrolyte abnormalities
*[[Electrolyte abnormalities]]
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* Poorly identifiable QRS complexes and absent P waves
* Poorly identifiable [[QRS complexes]] and absent [[P waves]]
* The heart rate is >300 BPM  
* The [[heart rate]] is >300 BPM
* Rhythm is irregular
*[[Rhythm]] is irregular
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[[File:Capture VF.PNG|center|300px]]<ref> ECG found in https://en.ecgpedia.org/index.php?title=Main_Page </ref>
[[File:Capture VF.PNG|center|300px]]<ref> ECG found in https://en.ecgpedia.org/index.php?title=Main_Page </ref>
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*[[Electrolyte disturbances]]
*[[Electrolyte disturbances]]
*Medications such as:
*[[Medications]] such as:
**[[Dysopyramide]]
**[[Disopyramide]]
**[[Quinidine]]
**[[Quinidine]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
*The ECG shows:
*The [[ECG]] shows:
**A typical sinusoidal pattern
**A typical [[sinusoidal]] pattern
**Frequency of 300 bpm
**Frequency of 300 bpm
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| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
[[File:Capture Ven Flu.PNG|center|300px]]<ref> ECG found in https://en.ecgpedia.org/index.php?title=Main_Page </ref>
[[File:Capture Ven Flu.PNG|center|300px]]<ref> ECG found in https://en.ecgpedia.org/index.php?title=Main_Page </ref>
|-
|-
! style="padding: 5px 5px; background: #DCDCDC;" align="left" | '''[[Asystole]]''' <ref name=ACLS_2003_H_T>''ACLS: Principles and Practice''. p. 71-87. Dallas: American Heart Association, 2003. ISBN 0-87493-341-2.</ref><ref name=ACLS_2003_EP_HT>''ACLS for Experienced Providers''. p. 3-5. Dallas: American Heart Association, 2003. ISBN 0-87493-424-9.</ref>
! style="padding: 5px 5px; background: #DCDCDC;" align="left" | '''[[Asystole]]''' <ref name="ACLS_2003_H_T">''ACLS: Principles and Practice''. p. 71-87. Dallas: American Heart Association, 2003. ISBN 0-87493-341-2.</ref><ref name="ACLS_2003_EP_HT">''ACLS for Experienced Providers''. p. 3-5. Dallas: American Heart Association, 2003. ISBN 0-87493-424-9.</ref>
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*[[Hypovolemia]]
*[[Hypovolemia]]
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[[Image:Lead II rhythm generated asystole.JPG|center|300px]]<ref> ECG found in https://en.ecgpedia.org/index.php?title=Main_Page </ref>
[[Image:Lead II rhythm generated asystole.JPG|center|300px]]<ref> ECG found in https://en.ecgpedia.org/index.php?title=Main_Page </ref>
|-
|-
! style="padding: 5px 5px; background: #DCDCDC;" align="left" | '''[[Pulseless electrical activity]]''' <ref name="ECC_2005_7.2">"2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care - Part 7.2: Management of Cardiac Arrest." ''Circulation'' 2005; '''112''': IV-58 - IV-66.</ref><ref>Foster B, Twelve Lead Electrocardiography, 2nd edition, 2007</ref>
! style="padding: 5px 5px; background: #DCDCDC;" align="left" | '''[[Pulseless electrical activity]]''' <ref name="ECC_2005_7.2">"2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care - Part 7.2: Management of Cardiac Arrest." ''Circulation'' 2005; '''112''': IV-58 - IV-66.</ref><ref>Foster B, Twelve Lead Electrocardiography, 2nd edition, 2007</ref><ref name="pmid24297818">{{cite journal |vauthors=Myerburg RJ, Halperin H, Egan DA, Boineau R, Chugh SS, Gillis AM, Goldhaber JI, Lathrop DA, Liu P, Niemann JT, Ornato JP, Sopko G, Van Eyk JE, Walcott GP, Weisfeldt ML, Wright JD, Zipes DP |title=Pulseless electric activity: definition, causes, mechanisms, management, and research priorities for the next decade: report from a National Heart, Lung, and Blood Institute workshop |journal=Circulation |volume=128 |issue=23 |pages=2532–41 |date=December 2013 |pmid=24297818 |doi=10.1161/CIRCULATIONAHA.113.004490 |url=}}</ref><ref name="pmid23949188">{{cite journal |vauthors=Littmann L, Bustin DJ, Haley MW |title=A simplified and structured teaching tool for the evaluation and management of pulseless electrical activity |journal=Med Princ Pract |volume=23 |issue=1 |pages=1–6 |date=2014 |pmid=23949188 |pmc=5586830 |doi=10.1159/000354195 |url=}}</ref>
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*Hypovolemia
*[[Hypovolemia]]
*Hypoxia
*[[Hypoxia]]
*Hydrogen ions (Acidosis)
*Hydrogen ions ([[Acidosis]])
*Hypothermia
*[[Hypothermia]]
*[[Electrolyte disturbances]]
*[[Electrolyte disturbances]]
*Hypoglycemia
*[[Hypoglycemia]]
*Tablets or Toxins (Drug overdose) such as beta blockers, tricyclic antidepressants, or calcium channel blockers
*[[Tablets]] or [[Toxins]] (Drug overdose) such as [[beta blockers]], [[tricyclic antidepressants]], or [[calcium channel blockers]]
*Tamponade
*[[Tamponade]]
*Tension pneumothorax
*[[Tension pneumothorax]]
*Thrombosis (Myocardial infarction)
*[[Thrombosis]] ([[Myocardial infarction]])
*Thrombosis (Pulmonary embolism)
*[[Thrombosis]] ([[Pulmonary embolism]])
*Trauma (Hypovolemia from blood loss)
*[[Trauma]] ([[Hypovolemia]] from [[blood loss]])
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*Several ppattern are possible including:
*Several pattern are possible including:
**Normal sinus rhythm
**[[Normal sinus rhythm]]
**Sinus tachycardia, with discernible P waves and QRS complexes
**[[Sinus tachycardia]], with discernible [[P waves]] and [[QRS complexes]]
**Bradycardia, with or without P waves
**[[Bradycardia]], with or without [[P waves]]
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[[File:Capture PEA.PNG|center|300px]]<ref> ECG found in wikimedia Commons </ref>
[[File:Capture PEA.PNG|center|300px]]<ref> ECG found in wikimedia Commons </ref>
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* *[[Electrolyte disturbances]]
* *[[Electrolyte disturbances]]
* Medications such as:
*[[Medications]] such as:
** [[Amiodarone]]
**[[Amiodarone]]
** [[Azithromycin ]]
**[[Azithromycin]]
** [[Clozapine ]]
**[[Clozapine]]
**[[Famotidine]]
**[[Famotidine]]
** [[Flecainide ]]
**[[Flecainide]]
** [[Foscarnet ]]
**[[Foscarnet]]
** [[Levofloxacin ]]
**[[Levofloxacin]]
** [[Lithium ]]
**[[Lithium]]
** [[Mirtazipine]]
**[[Mirtazapine]]
** [[Quetiapine ]]
**[[Quetiapine]]
** [[Risperidone ]]
**[[Risperidone]]
** [[Tacrolimus ]]
**[[Tacrolimus]]
** [[Tamoxifen ]]
**[[Tamoxifen]]
** [[Ziprasidone]]
**[[Ziprasidone]]
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# Paroxysms of VT with irregular RR intervals.
# Paroxysms of [[VT]] with irregular RR intervals.
# A ventricular rate between 200 and 250 beats per minute.
# A [[ventricular]] rate between 200 and 250 beats per minute.
# Two or more cycles of [[QRS complex]]es with alternating polarity.
# Two or more cycles of [[QRS complex]]es with alternating polarity.
# Changing amplitude of the QRS complexes in each cycle in a sinusoidal fashion.
# Changing amplitude of the [[QRS complexes]] in each cycle in a [[sinusoidal]] fashion.
# Prolongation of the [[QT interval]].
# Prolongation of the [[QT interval]].
# Is often initiated by a [[PVC]] with a long coupling interval, R on T phenomenon.
# Is often initiated by a [[PVC]] with a long coupling interval, R on T phenomenon.
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[[File:Capture Tors De P.PNG|center|300px]]<ref> ECG found in https://en.ecgpedia.org/index.php?title=Main_Page </ref>
[[File:Capture Tors De P.PNG|center|300px]]<ref> ECG found in https://en.ecgpedia.org/index.php?title=Main_Page </ref>
|}
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==References==
==References==
{{reflist|2}}
{{reflist|2}}

Latest revision as of 22:28, 7 July 2020
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1],Associate Editor(s)-in-Chief: Maneesha Nandimandalam, M.B.B.S.[2]

Overview

PEA(Pulseless electrical activity) should be differentiated from asystole and ventricular fibrillation, Ventricular flutter, Torsade de Pointes, Asystole etc.

Differentiating Pulseless Electrical Activity from Other Diseases

The table below provides information on the differential diagnosis of pulseless electrical activity in terms of ECG appearance:

Disease Name Causes ECG Characteristics ECG view
Ventricular tachycardia [1][2][3][4][5]
[6]
Ventricular fibrillation [7][8][9][10]
[11]
Ventricular flutter [12][13][14]
[15]
Asystole [16][17]
  • There is no electrical activity in the asystole
[18]
Pulseless electrical activity [19][20][21][22]
[23]
Torsade de Pointes [24][25][26]
  1. Paroxysms of VT with irregular RR intervals.
  2. A ventricular rate between 200 and 250 beats per minute.
  3. Two or more cycles of QRS complexes with alternating polarity.
  4. Changing amplitude of the QRS complexes in each cycle in a sinusoidal fashion.
  5. Prolongation of the QT interval.
  6. Is often initiated by a PVC with a long coupling interval, R on T phenomenon.
  7. There are usually 5 to 20 complexes in each cycle.
[27]

References

  1. ↑ Ajijola, Olujimi A.; Tung, Roderick; Shivkumar, Kalyanam (2014). "Ventricular tachycardia in ischemic heart disease substrates". Indian Heart Journal. 66: S24–S34. doi:10.1016/j.ihj.2013.12.039. ISSN 0019-4832.
  2. ↑ Meja Lopez, Eliany; Malhotra, Rohit (2019). "Ventricular Tachycardia in Structural Heart Disease". Journal of Innovations in Cardiac Rhythm Management. 10 (8): 3762–3773. doi:10.19102/icrm.2019.100801. ISSN 2156-3977.
  3. ↑ Coughtrie, Abigail L; Behr, Elijah R; Layton, Deborah; Marshall, Vanessa; Camm, A John; Shakir, Saad A W (2017). "Drugs and life-threatening ventricular arrhythmia risk: results from the DARE study cohort". BMJ Open. 7 (10): e016627. doi:10.1136/bmjopen-2017-016627. ISSN 2044-6055.
  4. ↑ El-Sherif, Nabil (2001). "Mechanism of Ventricular Arrhythmias in the Long QT Syndrome: On Hermeneutics". Journal of Cardiovascular Electrophysiology. 12 (8): 973–976. doi:10.1046/j.1540-8167.2001.00973.x. ISSN 1045-3873.
  5. ↑ de Riva, Marta; Watanabe, Masaya; Zeppenfeld, Katja (2015). "Twelve-Lead ECG of Ventricular Tachycardia in Structural Heart Disease". Circulation: Arrhythmia and Electrophysiology. 8 (4): 951–962. doi:10.1161/CIRCEP.115.002847. ISSN 1941-3149.
  6. ↑ ECG found in of https://en.ecgpedia.org/index.php?title=Main_Page
  7. ↑ Koplan BA, Stevenson WG (March 2009). "Ventricular tachycardia and sudden cardiac death". Mayo Clin. Proc. 84 (3): 289–97. doi:10.1016/S0025-6196(11)61149-X. PMC 2664600. PMID 19252119.
  8. ↑ Maury P, Sacher F, Rollin A, Mondoly P, Duparc A, Zeppenfeld K, Hascoet S (May 2017). "Ventricular arrhythmias and sudden death in tetralogy of Fallot". Arch Cardiovasc Dis. 110 (5): 354–362. doi:10.1016/j.acvd.2016.12.006. PMID 28222965.
  9. ↑ Saumarez RC, Camm AJ, Panagos A, Gill JS, Stewart JT, de Belder MA, Simpson IA, McKenna WJ (August 1992). "Ventricular fibrillation in hypertrophic cardiomyopathy is associated with increased fractionation of paced right ventricular electrograms". Circulation. 86 (2): 467–74. doi:10.1161/01.cir.86.2.467. PMID 1638716.
  10. ↑ Bektas, Firat; Soyuncu, Secgin (2012). "Hypokalemia-induced Ventricular Fibrillation". The Journal of Emergency Medicine. 42 (2): 184–185. doi:10.1016/j.jemermed.2010.05.079. ISSN 0736-4679.
  11. ↑ ECG found in https://en.ecgpedia.org/index.php?title=Main_Page
  12. ↑ Thies, Karl-Christian; Boos, Karin; Müller-Deile, Kai; Ohrdorf, Wolfgang; Beushausen, Thomas; Townsend, Peter (2000). "Ventricular flutter in a neonate—severe electrolyte imbalance caused by urinary tract infection in the presence of urinary tract malformation". The Journal of Emergency Medicine. 18 (1): 47–50. doi:10.1016/S0736-4679(99)00161-4. ISSN 0736-4679.
  13. ↑ Koster, Rudolph W.; Wellens, Hein J.J. (1976). "Quinidine-induced ventricular flutter and fibrillation without digitalis therapy". The American Journal of Cardiology. 38 (4): 519–523. doi:10.1016/0002-9149(76)90471-9. ISSN 0002-9149.
  14. ↑ Dhurandhar RW, Nademanee K, Goldman AM (1978). "Ventricular tachycardia-flutter associated with disopyramide therapy: a report of three cases". Heart Lung. 7 (5): 783–7. PMID 250503.
  15. ↑ ECG found in https://en.ecgpedia.org/index.php?title=Main_Page
  16. ↑ ACLS: Principles and Practice. p. 71-87. Dallas: American Heart Association, 2003. ISBN 0-87493-341-2.
  17. ↑ ACLS for Experienced Providers. p. 3-5. Dallas: American Heart Association, 2003. ISBN 0-87493-424-9.
  18. ↑ ECG found in https://en.ecgpedia.org/index.php?title=Main_Page
  19. ↑ "2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care - Part 7.2: Management of Cardiac Arrest." Circulation 2005; 112: IV-58 - IV-66.
  20. ↑ Foster B, Twelve Lead Electrocardiography, 2nd edition, 2007
  21. ↑ Myerburg RJ, Halperin H, Egan DA, Boineau R, Chugh SS, Gillis AM, Goldhaber JI, Lathrop DA, Liu P, Niemann JT, Ornato JP, Sopko G, Van Eyk JE, Walcott GP, Weisfeldt ML, Wright JD, Zipes DP (December 2013). "Pulseless electric activity: definition, causes, mechanisms, management, and research priorities for the next decade: report from a National Heart, Lung, and Blood Institute workshop". Circulation. 128 (23): 2532–41. doi:10.1161/CIRCULATIONAHA.113.004490. PMID 24297818.
  22. ↑ Littmann L, Bustin DJ, Haley MW (2014). "A simplified and structured teaching tool for the evaluation and management of pulseless electrical activity". Med Princ Pract. 23 (1): 1–6. doi:10.1159/000354195. PMC 5586830. PMID 23949188.
  23. ↑ ECG found in wikimedia Commons
  24. ↑ Li M, Ramos LG (July 2017). "Drug-Induced QT Prolongation And Torsades de Pointes". P T. 42 (7): 473–477. PMC 5481298. PMID 28674475.
  25. ↑ Sharain, Korosh; May, Adam M.; Gersh, Bernard J. (2015). "Chronic Alcoholism and the Danger of Profound Hypomagnesemia". The American Journal of Medicine. 128 (12): e17–e18. doi:10.1016/j.amjmed.2015.06.051. ISSN 0002-9343.
  26. ↑ Khan IA (2001). "Twelve-lead electrocardiogram of torsades de pointes". Tex Heart Inst J. 28 (1): 69. PMC 101137. PMID 11330748.
  27. ↑ ECG found in https://en.ecgpedia.org/index.php?title=Main_Page

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