Pulseless electrical activity overview: Difference between revisions
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==Diagnosis== | ==Diagnosis== | ||
===Diagnostic Study Of Choice=== | |||
===Echocardiography=== | ===Echocardiography=== | ||
A rapid beside echocardiogram can identify several rapidly reversible causes of PEA such as [[cardiac tamponade]], [[myocardial infarction]], [[cardiac rupture]] and underfilling of the ventricle due to [[hypovolemia]]. Elevated right heart filling pressures suggest [[pulmonary embolism]]. [[Tension pneumothorax]] can also be observed on a bedside echocardiogram. | A rapid beside echocardiogram can identify several rapidly reversible causes of PEA such as [[cardiac tamponade]], [[myocardial infarction]], [[cardiac rupture]] and underfilling of the ventricle due to [[hypovolemia]]. Elevated right heart filling pressures suggest [[pulmonary embolism]]. [[Tension pneumothorax]] can also be observed on a bedside echocardiogram. | ||
==Laboratory Findings== | ===Laboratory Findings=== | ||
Athough there are no [[diagnostic]] [[laboratory]] findings associated with PEA(pulseless electrical activity) testing should be ordered to rule out the most common reversible [[causes]] of PEA(pulseless electrical activity) like [[Hyperkalemia]] or [[Hypokalemia]], [[hypoxia]] and [[acidosis]] which can be seen with[[ABG]], [[exsanguination]] [[hematocrit]]. | Athough there are no [[diagnostic]] [[laboratory]] findings associated with PEA(pulseless electrical activity) testing should be ordered to rule out the most common reversible [[causes]] of PEA(pulseless electrical activity) like [[Hyperkalemia]] or [[Hypokalemia]], [[hypoxia]] and [[acidosis]] which can be seen with[[ABG]], [[exsanguination]] [[hematocrit]]. | ||
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Pulseless electrical activity is defined as the absence of a pulse or cardiac contractility despite the presence of electrocardiographic activity. The most common causes are respiratory failure and hypovolemia.
Pathophysiology
PEA( pulseless electrical activity) usually occurs when an insult involves the cardiovascular, gastrointestinal or the respiratory systems. Any such event can lead to decrease in cardiac contractility, and the situation gets even worse by potential acidosis, hypoxia, and worsening vagal tone. A severe initial insult often reduces cardiac output which may in turn cause myocardial ischemia, left ventricular failure, hypoxia and metabolic acidosis. These pathophysiologic disturbances further reduce cardiac output further exacerbating the downward spiral with loss of cardiac output; hypotension, loss of consciousness and apnea rapidly ensue. Other possible mechanisms for pulseless electrical activity include Elevated Afterload, Electromechanical Dissociation, Reduced Contractility, Parasympathetic theory.
Risk Factors
The administration of beta blockers and calcium channel blockers is associated with an increased risk of PEA. This may be due to their effect on Ca / troponin interactions, and their inhibition of myocardial contractility.
Natural History, Complications and Prognosis
PEA is associated with a poor prognosis, particularly if the underlying cause is not readily identifiable and treated. The presence of a QRS interval > 0.20 seconds is associated with a poorer prognosis. The survival of in hospital PEA is only 11.2%.[1] The survival for out of hospital occurrence of PEA is higher (19.5%) than for in hospital PEA, likely due to the higher incidence of reversible causes among patients with out of hospital arrest. The survival of PEA as a presenting rhythm is poorer than ventricular tachycardia or ventricular fibrillation.[2]
Diagnosis
Diagnostic Study Of Choice
Echocardiography
A rapid beside echocardiogram can identify several rapidly reversible causes of PEA such as cardiac tamponade, myocardial infarction, cardiac rupture and underfilling of the ventricle due to hypovolemia. Elevated right heart filling pressures suggest pulmonary embolism. Tension pneumothorax can also be observed on a bedside echocardiogram.
Laboratory Findings
Athough there are no diagnostic laboratory findings associated with PEA(pulseless electrical activity) testing should be ordered to rule out the most common reversible causes of PEA(pulseless electrical activity) like Hyperkalemia or Hypokalemia, hypoxia and acidosis which can be seen withABG, exsanguination hematocrit.
Treatment
Medical therapy
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 fluidsor 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.
Surgery
External and internal pacing have not been shown to improve outcome and are not recommended. There may be capture of the signals, but there is no improvement in contractility.
References
- ↑ Nadkarni VM, Larkin GL, Peberdy MA, Carey SM, Kaye W, Mancini ME, Nichol G, Lane-Truitt T, Potts J, Ornato JP, Berg RA (2006). "First documented rhythm and clinical outcome from in-hospital cardiac arrest among children and adults". JAMA : the Journal of the American Medical Association. 295 (1): 50–7. doi:10.1001/jama.295.1.50. PMID 16391216. Retrieved 2012-09-16. Unknown parameter
|month=ignored (help) - ↑ Meaney PA, Nadkarni VM, Kern KB, Indik JH, Halperin HR, Berg RA (2010). "Rhythms and outcomes of adult in-hospital cardiac arrest". Critical Care Medicine. 38 (1): 101–8. doi:10.1097/CCM.0b013e3181b43282. PMID 19770741. Retrieved 2012-09-16. Unknown parameter
|month=ignored (help)