Pulseless electrical activity medical therapy

Resident Survival Guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Medical Therapy

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:

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

Below is an algorithm summarizing the approach to a patient with pulseless electrical activity

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

If the patient develops PEA several days after presenting with a ST elevation MI, then recurrent MI should be considered.

Hyperkalemia

Consider this in the patient with chronic renal insufficiency or in the patient on hemodialysis.

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

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.

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. The dose of vasopressin is 40 U IV/IO.

Atropine

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. 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).

CPR

All of these drugs should be administered along with appropriate CPR techniques.

Defibrillation

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