Pulseless electrical activity medical therapy: Difference between revisions
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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 | ||
*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 | ||
Most common in patients with [[chronic renal insufficiency]] or in those on [[hemodialysis]]. Immediate replacement should be done to avoid complications | **Most common in patients with [[chronic renal insufficiency]] or in those on [[hemodialysis]]. Immediate replacement should be done to avoid complications | ||
*Hypothermia | *Hypothermia | ||
*Pulmonary Embolism | *Pulmonary Embolism | ||
Revision as of 17:54, 10 July 2020
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Pulseless electrical activity Microchapters |
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Differentiating Pulseless Electrical Activity from other Diseases |
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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.
- 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.
- 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.
- 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.
- 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.
- 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
- Most common in patients with chronic renal insufficiency or in those on hemodialysis. Immediate replacement should be done to avoid complications
- 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
- ↑ 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) - ↑ "The Approach to Cardiac Arrest".
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 6.0 6.1
- ↑ 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) - ↑ 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)