Pulseless electrical activity medical therapy: Difference between revisions

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{| class="infobox" style="float:right;"
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| [[File:Siren.gif|30px|link= Pulseless electrical activity resident survival guide]]|| <br> || <br>
| [[Pulseless electrical activity resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
|}
{{Pulseless electrical activity}}
{{Pulseless electrical activity}}
{{CMG}}
{{CMG}}; {{AE}} {{M.N}}


<br />
== Overview ==
The current American Heart Association-[[Advanced Cardiac Life Support]] (AHA-ACLS) guidelines advise the following be undertaken in all patients start [[CPR]] immediately, administer 100% [[oxygen]] to reverse [[hypoxia]],[[Intubate]] the patient, establish IV access.The mainstay of [[drug]] therapy for PEA is [[epinephrine]] 1mg every 3–5 minutes.  Higher doses of [[epinephrine]] can be administered in [[patients]] with suspected [[beta blocker]] and [[calcium channel blocker]] overdose. Immediately after administering [[epinephrine]] attention should be directed to reverse any possible causes of PEA as they are the most common [[causes]] like [[hypovolemia]] (i.e. [[hypovolemic shock]]) which should be treated with [[IV fluids]] hor [[packed red blood cell transfusion]]. Others like [[electrolyte]] abnormalities including hyper/[[hypokalemia]] should be corrected immediately as they can be life threatening as well as [[tension pneumothorax]].


== Overview ==
<br />
==Medical Therapy==
==Medical Therapy==
Below is an algorithm summarizing the approach to a patient with pulseless electrical activity.  
Below is an algorithm summarizing the approach to a patient with pulseless electrical activity. <ref name="EdelsonSasson2020">{{cite journal|last1=Edelson|first1=Dana P.|last2=Sasson|first2=Comilla|last3=Chan|first3=Paul S.|last4=Atkins|first4=Dianne L.|last5=Aziz|first5=Khalid|last6=Becker|first6=Lance B.|last7=Berg|first7=Robert A.|last8=Bradley|first8=Steven M.|last9=Brooks|first9=Steven C.|last10=Cheng|first10=Adam|last11=Escobedo|first11=Marilyn|last12=Flores|first12=Gustavo E.|last13=Girotra|first13=Saket|last14=Hsu|first14=Antony|last15=Kamath-Rayne|first15=Beena D.|last16=Lee|first16=Henry C.|last17=Lehotzky|first17=Rebecca E.|last18=Mancini|first18=Mary E.|last19=Merchant|first19=Raina M.|last20=Nadkarni|first20=Vinay M.|last21=Panchal|first21=Ashish R.|last22=Peberdy|first22=Mary Ann R.|last23=Raymond|first23=Tia T.|last24=Walsh|first24=Brian|last25=Wang|first25=David S.|last26=Zelop|first26=Carolyn M.|last27=Topjian|first27=Alexis|title=
            Interim Guidance for Basic and Advanced Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19:From the Emergency Cardiovascular Care Committee and Get With the Guidelines
            ®
            -Resuscitation Adult and Pediatric Task Forces of the American Heart Association in Collaboration with the American Academy of Pediatrics, American Association for Respiratory Care, American College of Emergency Physicians, The Society of Critical Care Anesthesiologists, and American Society of Anesthesiologists: Supporting Organizations: American Association of Critical Care Nurses and National EMS Physicians
          |journal=Circulation|year=2020|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.120.047463}}</ref>


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{{familytree/start}}
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===Initial Treatment in All Patients===
===Initial Treatment in All Patients===
The current American Heart Association-Advanced Cardiac Life Support (AHA-ACLS) guidelines advise the following be undertaken in all patients:<ref name="pmid209702862">{{cite journal| author=Mehta C, Brady W| title=Pulseless electrical activity in cardiac arrest: electrocardiographic presentations and management considerations based on the electrocardiogram. | journal=Am J Emerg Med | year= 2012 | volume= 30 | issue= 1 | pages= 236-9 | pmid=20970286 | doi=10.1016/j.ajem.2010.08.017 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20970286  }}</ref>The algorithm is based on the 2010 American Heart Association ACLS algorithm for PEA.<ref name="pmid20956217">{{cite journal| author=Field JM, Hazinski MF, Sayre MR, Chameides L, Schexnayder SM, Hemphill R et al.| title=Part 1: executive summary: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. | journal=Circulation | year= 2010 | volume= 122 | issue= 18 Suppl 3 | pages= S640-56 | pmid=20956217 | doi=10.1161/CIRCULATIONAHA.110.970889 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20956217  }} </ref>
The current American Heart Association-Advanced Cardiac Life Support (AHA-ACLS) guidelines advise the following be undertaken in all patients:<ref name="pmid209702862">{{cite journal| author=Mehta C, Brady W| title=Pulseless electrical activity in cardiac arrest: electrocardiographic presentations and management considerations based on the electrocardiogram. | journal=Am J Emerg Med | year= 2012 | volume= 30 | issue= 1 | pages= 236-9 | pmid=20970286 | doi=10.1016/j.ajem.2010.08.017 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20970286  }}</ref>The algorithm is based on the 2010 American Heart Association ACLS algorithm for PEA.<ref name="pmid20956217">{{cite journal| author=Field JM, Hazinski MF, Sayre MR, Chameides L, Schexnayder SM, Hemphill R et al.| title=Part 1: executive summary: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. | journal=Circulation | year= 2010 | volume= 122 | issue= 18 Suppl 3 | pages= S640-56 | pmid=20956217 | doi=10.1161/CIRCULATIONAHA.110.970889 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20956217  }} </ref><ref name="SoarMaconochie2019">{{cite journal|last1=Soar|first1=Jasmeet|last2=Maconochie|first2=Ian|last3=Wyckoff|first3=Myra H.|last4=Olasveengen|first4=Theresa M.|last5=Singletary|first5=Eunice M.|last6=Greif|first6=Robert|last7=Aickin|first7=Richard|last8=Bhanji|first8=Farhan|last9=Donnino|first9=Michael W.|last10=Mancini|first10=Mary E.|last11=Wyllie|first11=Jonathan P.|last12=Zideman|first12=David|last13=Andersen|first13=Lars W.|last14=Atkins|first14=Dianne L.|last15=Aziz|first15=Khalid|last16=Bendall|first16=Jason|last17=Berg|first17=Katherine M.|last18=Berry|first18=David C.|last19=Bigham|first19=Blair L.|last20=Bingham|first20=Robert|last21=Couto|first21=Thomaz Bittencourt|last22=Böttiger|first22=Bernd W.|last23=Borra|first23=Vere|last24=Bray|first24=Janet E.|last25=Breckwoldt|first25=Jan|last26=Brooks|first26=Steven C.|last27=Buick|first27=Jason|last28=Callaway|first28=Clifton W.|last29=Carlson|first29=Jestin N.|last30=Cassan|first30=Pascal|last31=Castrén|first31=Maaret|last32=Chang|first32=Wei-Tien|last33=Charlton|first33=Nathan P.|last34=Cheng|first34=Adam|last35=Chung|first35=Sung Phil|last36=Considine|first36=Julie|last37=Couper|first37=Keith|last38=Dainty|first38=Katie N.|last39=Dawson|first39=Jennifer Anne|last40=de Almeida|first40=Maria Fernanda|last41=de Caen|first41=Allan R.|last42=Deakin|first42=Charles D.|last43=Drennan|first43=Ian R.|last44=Duff|first44=Jonathan P.|last45=Epstein|first45=Jonathan L.|last46=Escalante|first46=Raffo|last47=Gazmuri|first47=Raúl J.|last48=Gilfoyle|first48=Elaine|last49=Granfeldt|first49=Asger|last50=Guerguerian|first50=Anne-Marie|last51=Guinsburg|first51=Ruth|last52=Hatanaka|first52=Tetsuo|last53=Holmberg|first53=Mathias J.|last54=Hood|first54=Natalie|last55=Hosono|first55=Shigeharu|last56=Hsieh|first56=Ming-Ju|last57=Isayama|first57=Tetsuya|last58=Iwami|first58=Taku|last59=Jensen|first59=Jan L.|last60=Kapadia|first60=Vishal|last61=Kim|first61=Han-Suk|last62=Kleinman|first62=Monica E.|last63=Kudenchuk|first63=Peter J.|last64=Lang|first64=Eddy|last65=Lavonas|first65=Eric|last66=Liley|first66=Helen|last67=Lim|first67=Swee Han|last68=Lockey|first68=Andrew|last69=Lofgren|first69=Bo|last70=Ma|first70=Matthew Huei-Ming|last71=Markenson|first71=David|last72=Meaney|first72=Peter A.|last73=Meyran|first73=Daniel|last74=Mildenhall|first74=Lindsay|last75=Monsieurs|first75=Koenraad G.|last76=Montgomery|first76=William|last77=Morley|first77=Peter T.|last78=Morrison|first78=Laurie J.|last79=Nadkarni|first79=Vinay M.|last80=Nation|first80=Kevin|last81=Neumar|first81=Robert W.|last82=Ng|first82=Kee-Chong|last83=Nicholson|first83=Tonia|last84=Nikolaou|first84=Nikolaos|last85=Nishiyama|first85=Chika|last86=Nuthall|first86=Gabrielle|last87=Ohshimo|first87=Shinichiro|last88=Okamoto|first88=Deems|last89=O’Neil|first89=Brian|last90=Yong-Kwang Ong|first90=Gene|last91=Paiva|first91=Edison F.|last92=Parr|first92=Michael|last93=Pellegrino|first93=Jeffrey L.|last94=Perkins|first94=Gavin D.|last95=Perlman|first95=Jeffrey|last96=Rabi|first96=Yacov|last97=Reis|first97=Amelia|last98=Reynolds|first98=Joshua C.|last99=Ristagno|first99=Giuseppe|last100=Roehr|first100=Charles C.|last101=Sakamoto|first101=Tetsuya|last102=Sandroni|first102=Claudio|last103=Schexnayder|first103=Stephen M.|last104=Scholefield|first104=Barnaby R.|last105=Shimizu|first105=Naoki|last106=Skrifvars|first106=Markus B.|last107=Smyth|first107=Michael A.|last108=Stanton|first108=David|last109=Swain|first109=Janel|last110=Szyld|first110=Edgardo|last111=Tijssen|first111=Janice|last112=Travers|first112=Andrew|last113=Trevisanuto|first113=Daniele|last114=Vaillancourt|first114=Christian|last115=Van de Voorde|first115=Patrick|last116=Velaphi|first116=Sithembiso|last117=Wang|first117=Tzong-Luen|last118=Weiner|first118=Gary|last119=Welsford|first119=Michelle|last120=Woodin|first120=Jeff A.|last121=Yeung|first121=Joyce|last122=Nolan|first122=Jerry P.|last123=Fran Hazinski|first123=Mary|title=2019 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces|journal=Circulation|volume=140|issue=24|year=2019|issn=0009-7322|doi=10.1161/CIR.0000000000000734}}</ref>
 


*Start CPR immediately
*Start CPR immediately
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===Reverse The Underlying Cause===
===Reverse The Underlying Cause===
The mainstay of treatment is to reverse the underlying cause of PEA.
The mainstay of treatment is to reverse the underlying cause of PEA.
====Hypovolemic Shock====
#Hypovolemic Shock
The most common reversible cause is [[hypovolemia]] (i.e. [[hypovolemic shock]]) which should be treated with [[IV fluids]] or [[packed red blood cell transfusion]].  
*The most common reversible cause is [[hypovolemia]] (i.e. [[hypovolemic shock]]) which should be treated with [[IV fluids]] or [[packed red blood cell transfusion]].  
====Tension Pneumothorax====
#Tension Pneumothorax
Another readily identifiable and immediately treatable causes include [[tension pneumothorax]] (not uncommon in the ICU setting).  Often in the ICU, this may occur in a ventilated patient, but conscious patients may complain of the sudden onset of [[chest pain]], there may be the sudden appearance of [[cyanosis]], [[tracheal deviation]], and [[absent breath sounds]] on the involved side of the chest.  In patients on a ventilator, auto ̶ [[positive end-expiratory pressure]] (auto [[PEEP]]) and rupture of a bleb are more likely to occur.  A thin needle can be inserted in the upper intercostal space to relieve the pressure and allow the lung to reinflate.
Another readily identifiable and immediately treatable causes include [[tension pneumothorax]] (not uncommon in the ICU setting).  Often in the ICU, this may occur in a ventilated patient, but conscious patients may complain of the sudden onset of [[chest pain]], there may be the sudden appearance of [[cyanosis]], [[tracheal deviation]], and [[absent breath sounds]] on the involved side of the chest.  In patients on a ventilator, auto ̶ [[positive end-expiratory pressure]] (auto [[PEEP]]) and rupture of a bleb are more likely to occur.  A thin needle can be inserted in the upper intercostal space to relieve the pressure and allow the lung to reinflate.
====Cardiac Tamponade====
*Cardiac Tamponade
Suspect cardiac tamponade in the patient with recent chest trauma,neoplasm, or renal failure. These patients will complain of preceding sudden onset of [[chest pain]], [[palpitations]], [[breathlessness]] and [[lightheadedness]]. [[Elevated neck veins]] and a quiet muffled heart are present.  There may be [[electrical alternans]] of the [[QRS complex]] and other intervals on the EKG.
**Suspect cardiac tamponade in the patient with recent chest trauma,neoplasm, or renal failure. These patients will complain of preceding sudden onset of [[chest pain]], [[palpitations]], [[breathlessness]] and [[lightheadedness]]. [[Elevated neck veins]] and a quiet muffled heart are present.  There may be [[electrical alternans]] of the [[QRS complex]] and other intervals on the EKG.
====Cardiac Rupture====
*Cardiac Rupture
If the patient develops PEA several days after presenting with a ST elevation MI, then cardiac rupture should be considered particularly in an elderly female with hypertension.
If the patient develops PEA several days after presenting with a ST elevation MI, then cardiac rupture should be considered particularly in an elderly female with hypertension.
====Recurrent Myocardial Infarction====
*Recurrent Myocardial Infarction
If the patient develops PEA several days after presenting with a ST elevation MI, then recurrent MI should be considered.
*8If the patient develops PEA several days after presenting with a ST elevation MI, then recurrent MI should be considered and treated accordingly
====Hyperkalemia====
*Hyperkalemia
Consider this in the patient with [[chronic renal insufficiency]] or in the patient on [[hemodialysis]].
**Most common in patients with [[chronic renal insufficiency]] or in those on [[hemodialysis]]. Immediate replacement should be done to avoid complications
====Hypothermia====
*Hypothermia
"No patient is dead unless they are warm and dead." Confirm that a newly hospitalized patient is not [[hypothermic]] with a core temperature.  Longer resuscitative efforts can be undertaken in the [[hypothermic]] patient.
*Pulmonary Embolism
====Pulmonary Embolism====
New [[right axis deviation]] on the EKG suggests [[PE]].
New [[right axis deviation]] on the EKG suggests [[PE]].
===Treatment in the Absence of an Identifiable Underlying Cause===
===Treatment in the Absence of an Identifiable Underlying Cause===
If an underlying cause for PEA cannot be determined and/or reversed, the treatment of pulseless electrical activity is similar to that for [[asystole]].<ref name="2010AHA" />
If an underlying cause for PEA cannot be determined and/or reversed, the treatment of pulseless electrical activity is similar to that for [[asystole]].<ref name="2010AHA" />
 
*Epinephrine
===Epinephrine===
The mainstay of drug therapy for PEA is [[epinephrine]] 1mg every 3–5 minutes.  Higher doses of epinephrine can be administered in patients with suspected [[beta blocker]] and [[calcium channel blocker]] overdose.  Otherwise high dose epinephrine has not demonstrated a benefit in survival or neurologic recovery.
The mainstay of drug therapy for PEA is [[epinephrine]] 1mg every 3–5 minutes.  Higher doses of epinephrine can be administered in patients with suspected [[beta blocker]] and [[calcium channel blocker]] overdose.  Otherwise high dose epinephrine has not demonstrated a benefit in survival or neurologic recovery.
 
*Vasopressin
===Vasopressin===
Vasopressin can replace epinephrine as either the first or second dose of resuscitative pharmacotherapy.<ref name="pmid19384647">{{cite journal | author = Grmec S, Strnad M, Cander D, Mally S | title = A treatment protocol including vasopressin and hydroxyethyl starch solution is associated with increased rate of return of spontaneous circulation in blunt trauma patients with pulseless electrical activity | journal = International Journal of Emergency Medicine | volume = 1 | issue = 4 | pages = 311–6 | year = 2008 | month = December | pmid = 19384647 | pmc = 2657262 | doi = 10.1007/s12245-008-0073-8 | url = http://www.intjem.com/content/1/4/311 | issn = | accessdate = 2012-09-16}}</ref> <ref name="pmid19390921">{{cite journal | author = Kotak D | title = Comment on Grmec et al.: a treatment protocol including vasopressin and hydroxyethyl starch solution is associated with increased rate of return of spontaneous circulation in blunt trauma patients with pulseless electrical activity | journal = International Journal of Emergency Medicine | volume = 2 | issue = 1 | pages = 57–8 | year = 2009 | month = April | pmid = 19390921 | pmc = 2672974 | doi = 10.1007/s12245-008-0079-2 | url = http://www.intjem.com/content/2/1/57 | issn = | accessdate = 2012-09-16}}</ref>The dose of vasopressin is 40 U IV/IO.
Vasopressin can replace epinephrine as either the first or second dose of resuscitative pharmacotherapy.<ref name="pmid19384647">{{cite journal | author = Grmec S, Strnad M, Cander D, Mally S | title = A treatment protocol including vasopressin and hydroxyethyl starch solution is associated with increased rate of return of spontaneous circulation in blunt trauma patients with pulseless electrical activity | journal = International Journal of Emergency Medicine | volume = 1 | issue = 4 | pages = 311–6 | year = 2008 | month = December | pmid = 19384647 | pmc = 2657262 | doi = 10.1007/s12245-008-0073-8 | url = http://www.intjem.com/content/1/4/311 | issn = | accessdate = 2012-09-16}}</ref> <ref name="pmid19390921">{{cite journal | author = Kotak D | title = Comment on Grmec et al.: a treatment protocol including vasopressin and hydroxyethyl starch solution is associated with increased rate of return of spontaneous circulation in blunt trauma patients with pulseless electrical activity | journal = International Journal of Emergency Medicine | volume = 2 | issue = 1 | pages = 57–8 | year = 2009 | month = April | pmid = 19390921 | pmc = 2672974 | doi = 10.1007/s12245-008-0079-2 | url = http://www.intjem.com/content/2/1/57 | issn = | accessdate = 2012-09-16}}</ref>The dose of vasopressin is 40 U IV/IO.
===Atropine===
*Sodium bicorbonate
Although [[atropine]] was previously recommended in the treatment of PEA/asystole, this recommendation was withdrawn in 2010 by the American Heart Association due to lack of evidence for therapeutic benefit.<ref name="2010AHA">{{cite journal |author=2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care |title=Part 8: Adult Advanced Cardiovascular Life Support|journal=Circulation  |year=2010 |month=November |volume=122 |issue=18 Suppl |pages=S729–S767 | doi=10.1161/CIRCULATIONAHA.110.970988|url=http://circ.ahajournals.org/cgi/content/full/122/18_suppl_3/S729 |pmid=20956224}}</ref> If the pulse is < 60 beats per minute, atropine can still be administered in the full [[vagolytic]] dose of 1 mg IV q3-5min, up to 3 doses.  After atropine administration, it can become difficult to assess neurologic recovery.
===Na Bicorbonate===
Sodium bicarbonate at a dose of 1 meq per kilogram may be considered in this rhythm as well, although there is little evidence to support this practice. Its routine use is not recommended for patients in this context, except in special situations (e.g. preexisting [[metabolic acidosis]], [[hyperkalemia]], [[tricyclic antidepressant overdose]]).<ref name="2010AHA" />
Sodium bicarbonate at a dose of 1 meq per kilogram may be considered in this rhythm as well, although there is little evidence to support this practice. Its routine use is not recommended for patients in this context, except in special situations (e.g. preexisting [[metabolic acidosis]], [[hyperkalemia]], [[tricyclic antidepressant overdose]]).<ref name="2010AHA" />
===CPR===
===CPR===
All of these drugs should be administered along with appropriate [[CPR]] techniques.
All of the above mentioned drugs should be administered along with appropriate [[CPR]] technique. When performing [[CPR]] in covid-19 positive patients the following precautions should be taken:
*PPE(personal protective equipment) should be worn always depending upon the availability before beginning [[CPR]]
*Try to minimize the head count of persons performing CPR as much as possible and also use a negative-pressure room if it is available
*Using a mechanical device to perform [[CPR]] if available, high-efficiency particulate air (HEPA) filter for bag-mask ventilation (BMV) and mechanical ventilation
*Accessing the need for early intubation
*Always avoid prolonged resuscitation efforts given the high mortality rate of adult COVID-19 patients presenting with cardiac arrest
 
===Defibrillation===
===Defibrillation===
[[Defibrillation]] is '''''not''''' used to treat this rhythm, as the problem lies in the response of the myocardial tissue to electrical impulses.
[[Defibrillation]] is '''''not''''' used to treat this rhythm, as the problem lies in the response of the myocardial tissue to electrical impulses.
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[[Category:Emergency medicine]]
[[Category:Emergency medicine]]
[[Category:Intensive care medicine]]
[[Category:Intensive care medicine]]
[[Category:Needs content]]
[[Category:Up to date]]
[[Category:Needs overview]]
[[Category:Medicine]]

Latest revision as of 17:55, 10 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

The current American Heart Association-Advanced Cardiac Life Support (AHA-ACLS) guidelines advise the following be undertaken in all patients start CPR immediately, administer 100% oxygen to reverse hypoxia,Intubate the patient, establish IV access.The mainstay of drug therapy for PEA is epinephrine 1mg every 3–5 minutes. Higher doses of epinephrine can be administered in patients with suspected beta blocker and calcium channel blocker overdose. Immediately after administering epinephrine attention should be directed to reverse any possible causes of PEA as they are the most common causes like hypovolemia (i.e. hypovolemic shock) which should be treated with IV fluids hor packed red blood cell transfusion. Others like electrolyte abnormalities including hyper/hypokalemia should be corrected immediately as they can be life threatening as well as tension pneumothorax.

Medical Therapy

Below is an algorithm summarizing the approach to a patient with pulseless electrical activity. [1]

 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pulseless electrical activity
[2]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Start CPR for 2 minutes
Give oxygen
Attach monitor and defibrillator
IV/IO access
Epinephrine Q3-5 min
Consider advanced airway, capnography
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Rhythm
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Shockable
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Non-shockable
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
See VF/VT algorithm
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
CPR for 2 minutes
Treat Hs&Ts
Epinephrine Q3-5min
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Rhythm
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Shockable
 
 
 
 
 
 
 
 
 
 
 
 
 
Non-shockable
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
ROSC(return of spontaneous circulation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Post–Cardiac Arrest Care
 
 
 
 
 
 
 
 

Initial Treatment in All Patients

The current American Heart Association-Advanced Cardiac Life Support (AHA-ACLS) guidelines advise the following be undertaken in all patients:[3]The algorithm is based on the 2010 American Heart Association ACLS algorithm for PEA.[4][5]


  • Start CPR immediately
  • Administer 100% oxygen to reverse hypoxia
  • Intubate the patient
  • Establish IV access

Reverse The Underlying Cause

The mainstay of treatment is to reverse the underlying cause of PEA.

  1. Hypovolemic Shock
  1. Tension Pneumothorax

Another readily identifiable and immediately treatable causes include tension pneumothorax (not uncommon in the ICU setting). Often in the ICU, this may occur in a ventilated patient, but conscious patients may complain of the sudden onset of chest pain, there may be the sudden appearance of cyanosis, tracheal deviation, and absent breath sounds on the involved side of the chest. In patients on a ventilator, auto ̶ positive end-expiratory pressure (auto PEEP) and rupture of a bleb are more likely to occur. A thin needle can be inserted in the upper intercostal space to relieve the pressure and allow the lung to reinflate.

If the patient develops PEA several days after presenting with a ST elevation MI, then cardiac rupture should be considered particularly in an elderly female with hypertension.

  • Recurrent Myocardial Infarction
  • 8If the patient develops PEA several days after presenting with a ST elevation MI, then recurrent MI should be considered and treated accordingly
  • Hyperkalemia
  • Hypothermia
  • Pulmonary Embolism

New right axis deviation on the EKG suggests PE.

Treatment in the Absence of an Identifiable Underlying Cause

If an underlying cause for PEA cannot be determined and/or reversed, the treatment of pulseless electrical activity is similar to that for asystole.[6]

  • Epinephrine

The mainstay of drug therapy for PEA is epinephrine 1mg every 3–5 minutes. Higher doses of epinephrine can be administered in patients with suspected beta blocker and calcium channel blocker overdose. Otherwise high dose epinephrine has not demonstrated a benefit in survival or neurologic recovery.

  • Vasopressin

Vasopressin can replace epinephrine as either the first or second dose of resuscitative pharmacotherapy.[7] [8]The dose of vasopressin is 40 U IV/IO.

  • Sodium bicorbonate

Sodium bicarbonate at a dose of 1 meq per kilogram may be considered in this rhythm as well, although there is little evidence to support this practice. Its routine use is not recommended for patients in this context, except in special situations (e.g. preexisting metabolic acidosis, hyperkalemia, tricyclic antidepressant overdose).[6]

CPR

All of the above mentioned drugs should be administered along with appropriate CPR technique. When performing CPR in covid-19 positive patients the following precautions should be taken:

  • PPE(personal protective equipment) should be worn always depending upon the availability before beginning CPR
  • Try to minimize the head count of persons performing CPR as much as possible and also use a negative-pressure room if it is available
  • Using a mechanical device to perform CPR if available, high-efficiency particulate air (HEPA) filter for bag-mask ventilation (BMV) and mechanical ventilation
  • Accessing the need for early intubation
  • Always avoid prolonged resuscitation efforts given the high mortality rate of adult COVID-19 patients presenting with cardiac arrest

Defibrillation

Defibrillation is not used to treat this rhythm, as the problem lies in the response of the myocardial tissue to electrical impulses.

References

  1. ↑ Edelson, Dana P.; Sasson, Comilla; Chan, Paul S.; Atkins, Dianne L.; Aziz, Khalid; Becker, Lance B.; Berg, Robert A.; Bradley, Steven M.; Brooks, Steven C.; Cheng, Adam; Escobedo, Marilyn; Flores, Gustavo E.; Girotra, Saket; Hsu, Antony; Kamath-Rayne, Beena D.; Lee, Henry C.; Lehotzky, Rebecca E.; Mancini, Mary E.; Merchant, Raina M.; Nadkarni, Vinay M.; Panchal, Ashish R.; Peberdy, Mary Ann R.; Raymond, Tia T.; Walsh, Brian; Wang, David S.; Zelop, Carolyn M.; Topjian, Alexis (2020). "Interim Guidance for Basic and Advanced Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19:From the Emergency Cardiovascular Care Committee and Get With the Guidelines ® -Resuscitation Adult and Pediatric Task Forces of the American Heart Association in Collaboration with the American Academy of Pediatrics, American Association for Respiratory Care, American College of Emergency Physicians, The Society of Critical Care Anesthesiologists, and American Society of Anesthesiologists: Supporting Organizations: American Association of Critical Care Nurses and National EMS Physicians". Circulation. doi:10.1161/CIRCULATIONAHA.120.047463. ISSN 0009-7322. line feed character in |title= at position 201 (help)
  2. ↑ "The Approach to Cardiac Arrest".
  3. ↑ Mehta C, Brady W (2012). "Pulseless electrical activity in cardiac arrest: electrocardiographic presentations and management considerations based on the electrocardiogram". Am J Emerg Med. 30 (1): 236–9. doi:10.1016/j.ajem.2010.08.017. PMID 20970286.
  4. ↑ Field JM, Hazinski MF, Sayre MR, Chameides L, Schexnayder SM, Hemphill R; et al. (2010). "Part 1: executive summary: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care". Circulation. 122 (18 Suppl 3): S640–56. doi:10.1161/CIRCULATIONAHA.110.970889. PMID 20956217.
  5. ↑ Soar, Jasmeet; Maconochie, Ian; Wyckoff, Myra H.; Olasveengen, Theresa M.; Singletary, Eunice M.; Greif, Robert; Aickin, Richard; Bhanji, Farhan; Donnino, Michael W.; Mancini, Mary E.; Wyllie, Jonathan P.; Zideman, David; Andersen, Lars W.; Atkins, Dianne L.; Aziz, Khalid; Bendall, Jason; Berg, Katherine M.; Berry, David C.; Bigham, Blair L.; Bingham, Robert; Couto, Thomaz Bittencourt; Böttiger, Bernd W.; Borra, Vere; Bray, Janet E.; Breckwoldt, Jan; Brooks, Steven C.; Buick, Jason; Callaway, Clifton W.; Carlson, Jestin N.; Cassan, Pascal; Castrén, Maaret; Chang, Wei-Tien; Charlton, Nathan P.; Cheng, Adam; Chung, Sung Phil; Considine, Julie; Couper, Keith; Dainty, Katie N.; Dawson, Jennifer Anne; de Almeida, Maria Fernanda; de Caen, Allan R.; Deakin, Charles D.; Drennan, Ian R.; Duff, Jonathan P.; Epstein, Jonathan L.; Escalante, Raffo; Gazmuri, Raúl J.; Gilfoyle, Elaine; Granfeldt, Asger; Guerguerian, Anne-Marie; Guinsburg, Ruth; Hatanaka, Tetsuo; Holmberg, Mathias J.; Hood, Natalie; Hosono, Shigeharu; Hsieh, Ming-Ju; Isayama, Tetsuya; Iwami, Taku; Jensen, Jan L.; Kapadia, Vishal; Kim, Han-Suk; Kleinman, Monica E.; Kudenchuk, Peter J.; Lang, Eddy; Lavonas, Eric; Liley, Helen; Lim, Swee Han; Lockey, Andrew; Lofgren, Bo; Ma, Matthew Huei-Ming; Markenson, David; Meaney, Peter A.; Meyran, Daniel; Mildenhall, Lindsay; Monsieurs, Koenraad G.; Montgomery, William; Morley, Peter T.; Morrison, Laurie J.; Nadkarni, Vinay M.; Nation, Kevin; Neumar, Robert W.; Ng, Kee-Chong; Nicholson, Tonia; Nikolaou, Nikolaos; Nishiyama, Chika; Nuthall, Gabrielle; Ohshimo, Shinichiro; Okamoto, Deems; O’Neil, Brian; Yong-Kwang Ong, Gene; Paiva, Edison F.; Parr, Michael; Pellegrino, Jeffrey L.; Perkins, Gavin D.; Perlman, Jeffrey; Rabi, Yacov; Reis, Amelia; Reynolds, Joshua C.; Ristagno, Giuseppe; Roehr, Charles C.; Sakamoto, Tetsuya; Sandroni, Claudio; Schexnayder, Stephen M.; Scholefield, Barnaby R.; Shimizu, Naoki; Skrifvars, Markus B.; Smyth, Michael A.; Stanton, David; Swain, Janel; Szyld, Edgardo; Tijssen, Janice; Travers, Andrew; Trevisanuto, Daniele; Vaillancourt, Christian; Van de Voorde, Patrick; Velaphi, Sithembiso; Wang, Tzong-Luen; Weiner, Gary; Welsford, Michelle; Woodin, Jeff A.; Yeung, Joyce; Nolan, Jerry P.; Fran Hazinski, Mary (2019). "2019 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces". Circulation. 140 (24). doi:10.1161/CIR.0000000000000734. ISSN 0009-7322.
  6. ↑ 6.0 6.1
  7. ↑ Grmec S, Strnad M, Cander D, Mally S (2008). "A treatment protocol including vasopressin and hydroxyethyl starch solution is associated with increased rate of return of spontaneous circulation in blunt trauma patients with pulseless electrical activity". International Journal of Emergency Medicine. 1 (4): 311–6. doi:10.1007/s12245-008-0073-8. PMC 2657262. PMID 19384647. Retrieved 2012-09-16. Unknown parameter |month= ignored (help)
  8. ↑ Kotak D (2009). "Comment on Grmec et al.: a treatment protocol including vasopressin and hydroxyethyl starch solution is associated with increased rate of return of spontaneous circulation in blunt trauma patients with pulseless electrical activity". International Journal of Emergency Medicine. 2 (1): 57–8. doi:10.1007/s12245-008-0079-2. PMC 2672974. PMID 19390921. Retrieved 2012-09-16. Unknown parameter |month= ignored (help)

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