Pulseless electrical activity causes

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

Overview

Pulseless electrical activity is the initial presenting rhythm in 19.6% of patients who are monitored at the onset of cardiac arrest and 16.5% of patients who present to a prehospital system in full cardiac arrest. ^[1]

Causes

Life Threatening Causes

Pulseless electrical activity is a life-threatening condition and must be treated as such irrespective of the causes. Life-threatening conditions can result in death or permanent disability within 24 hours if left untreated.

Common Causes

Common causes of PEA include preceding respiratory failure in 40% to 50% of cases, and hypovolemia. The common causes of PEA can be remembered using the mnemonic "The Hs and Ts".^[2]^[3]^[4]

Hypovolemia
Hypoxia^[5]
Hydrogen ions (Acidosis)
Hypothermia
Hyperkalemia or Hypokalemia
Hypoglycemia
Tablets or Toxins (Drug overdose) such as beta blockers, tricyclic antidepressants, or calcium channel blockers
Tamponade
Tension pneumothorax
Thrombosis (Myocardial infarction)
Thrombosis (Pulmonary embolism)
Trauma (Hypovolemia from blood loss)

As noted by repeated balloon inflations in the cardiac catheterization laboratory, transient occlusion of the coronary artery does not cause PEA.

Causes by Organ System

Cardiovascular	Acute coronary syndrome, Brugada syndrome, cardiac amyloidosis^[6],Cardiac tamponade, cardiac tumor, complete heart block, congenital heart disease, congestive heart failure, dilated cardiomyopathy, hypertensive heart disease, hypertrophic cardiomyopathy, ischemic heart disease, long QT syndrome, myocardial infarction, myocarditis, NSTEMI, pericarditis, Rheumatic valvular disease^[7], STEMI, valvular heart disease
Chemical/Poisoning	Alcohol
Dental	No underlying causes
Dermatologic	No underlying causes
Drug Side Effect	beta-blockers, calcium channel blockers,digitalis, methylphenidate^[8], propofol, pyridostigmine, quinidine, risperidone^[9]
Ear Nose Throat	No underlying causes
Endocrine	Diabetic ketoacidosis, hypoglycemia
Environmental	Hypothermia
Gastroenterologic	No underlying causes
Genetic	Brugada syndrome, congenital heart block, congenital heart disease, Kearns-Sayre syndrome
Hematologic	No underlying causes
Iatrogenic	cardiac transplantation, coronary artery bypass grafting, heart surgery, hypertrophic cardiomyopathy alcohol septal ablation^[10]postdefibrillation^[11]
Infectious Disease	aspiration pneumonia, myocarditis, pericarditis, septic shock
Musculoskeletal/Orthopedic	No underlying causes
Neurologic	Seizure
Nutritional/Metabolic	Hypermagnesemia, metabolic acidosis
Obstetric/Gynecologic	No underlying causes
Oncologic	Cardiac tumor
Ophthalmologic	No underlying causes
Overdose/Toxicity	Alcohol^[12], propofol, quinidine
Psychiatric	Takotsubo cardiomyopathy
Pulmonary	Aspiration pneumonia, bronchospasm, hypoxia, tension pneumothorax
Renal/Electrolyte	Hyperkalemia, Hypovolemia, renal failure
Rheumatology/Immunology/Allergy	Cardiac amyloidosis^[6], Rheumatic valvular disease
Sexual	No underlying causes
Trauma	Myocardial contusion, severe brain injury
Urologic	No underlying causes
Miscellaneous	No underlying causes

Causes in Alphabetical Order

References

↑ Stueven H, Troiano P, Thompson B, Mateer JR, Kastenson EH, Tonsfeldt D; et al. (1986). "Bystander/first responder CPR: ten years experience in a paramedic system". Ann Emerg Med. 15 (6): 707–10. PMID 3706861.
↑ ACLS: Principles and Practice. p. 71-87. Dallas: American Heart Association, 2003. ISBN 0-87493-341-2.
↑ ACLS for Experienced Providers. p. 3-5. Dallas: American Heart Association, 2003. ISBN 0-87493-424-9.
↑ "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.
↑ Sandberg WS (2005). "Endobronchial blocker dislodgement leading to pulseless electrical activity". Anesth Analg. 100 (6): 1728–30. doi:10.1213/01.ANE.0000149895.99151.20. PMID 15920204.
↑ ^6.0 ^6.1 ^6.2 Hess EP, White RD (2004). "Out-of-hospital cardiac arrest in patients with cardiac amyloidosis: presenting rhythms, management and outcomes in four patients". Resuscitation. 60 (1): 105–11. doi:10.1016/j.resuscitation.2003.08.007. PMID 14987790.
↑ Virkkunen I, Paasio L, Ryynänen S, Vuori A, Sajantila A, Yli-Hankala A; et al. (2008). "Pulseless electrical activity and unsuccessful out-of-hospital resuscitation: what is the cause of death?". Resuscitation. 77 (2): 207–10. doi:10.1016/j.resuscitation.2007.12.006. PMID 18249482.
↑ ^8.0 ^8.1 Daly MW, Custer G, McLeay PD (2008). "Cardiac arrest with pulseless electrical activity associated with methylphenidate in an adolescent with a normal baseline echocardiogram". Pharmacotherapy. 28 (11): 1408–12. doi:10.1592/phco.28.11.1408. PMID 18957001.
↑ ^9.0 ^9.1 Ravin DS, Levenson JW (1997). "Fatal cardiac event following initiation of risperidone therapy". Ann Pharmacother. 31 (7–8): 867–70. PMID 9220048.
↑ ^10.0 ^10.1 ten Cate FJ, Soliman OI, Michels M, Theuns DA, de Jong PL, Geleijnse ML, Serruys PW (2010). "Long-term outcome of alcohol septal ablation in patients with obstructive hypertrophic cardiomyopathy: a word of caution". Circulation. Heart Failure. 3 (3): 362–9. doi:10.1161/CIRCHEARTFAILURE.109.862359. PMID 20332420. Retrieved 2012-02-11. Unknown parameter |month= ignored (help)
↑ ^11.0 ^11.1 Geddes LA, Roeder RA, Rundell AE, Otlewski MP, Kemeny AE, Lottes AE (2006). "The natural biochemical changes during ventricular fibrillation with cardiopulmonary resuscitation and the onset of postdefibrillation pulseless electrical activity". Am J Emerg Med. 24 (5): 577–81. doi:10.1016/j.ajem.2006.01.030. PMID 16938597.
↑ Stueven HA, Aufderheide T, Waite EM, Mateer JR (1989). "Electromechanical dissociation: six years prehospital experience". Resuscitation. 17 (2): 173–82. PMID 2546233.
↑ Peppriell JE, Bacon DR (2000). "Acute abdominal compartment syndrome with pulseless electrical activity during colonoscopy with conscious sedation". J Clin Anesth. 12 (3): 216–9. PMID 10869921.

Template:WH Template:WS

[pmid3706861-1] Stueven H, Troiano P, Thompson B, Mateer JR, Kastenson EH, Tonsfeldt D; et al. (1986). "Bystander/first responder CPR: ten years experience in a paramedic system". Ann Emerg Med. 15 (6): 707–10. PMID 3706861.

[ACLS_2003_H_T-2] ACLS: Principles and Practice. p. 71-87. Dallas: American Heart Association, 2003. ISBN 0-87493-341-2.

[ACLS_2003_EP_HT-3] ACLS for Experienced Providers. p. 3-5. Dallas: American Heart Association, 2003. ISBN 0-87493-424-9.

[ECC_2005_7.2-4] "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.

[pmid15920204-5] Sandberg WS (2005). "Endobronchial blocker dislodgement leading to pulseless electrical activity". Anesth Analg. 100 (6): 1728–30. doi:10.1213/01.ANE.0000149895.99151.20. PMID 15920204.

[pmid14987790-6] 6.0 ^6.1 ^6.2 Hess EP, White RD (2004). "Out-of-hospital cardiac arrest in patients with cardiac amyloidosis: presenting rhythms, management and outcomes in four patients". Resuscitation. 60 (1): 105–11. doi:10.1016/j.resuscitation.2003.08.007. PMID 14987790.

[pmid18249482-7] Virkkunen I, Paasio L, Ryynänen S, Vuori A, Sajantila A, Yli-Hankala A; et al. (2008). "Pulseless electrical activity and unsuccessful out-of-hospital resuscitation: what is the cause of death?". Resuscitation. 77 (2): 207–10. doi:10.1016/j.resuscitation.2007.12.006. PMID 18249482.

[pmid18957001-8] 8.0 ^8.1 Daly MW, Custer G, McLeay PD (2008). "Cardiac arrest with pulseless electrical activity associated with methylphenidate in an adolescent with a normal baseline echocardiogram". Pharmacotherapy. 28 (11): 1408–12. doi:10.1592/phco.28.11.1408. PMID 18957001.

[pmid9220048-9] 9.0 ^9.1 Ravin DS, Levenson JW (1997). "Fatal cardiac event following initiation of risperidone therapy". Ann Pharmacother. 31 (7–8): 867–70. PMID 9220048.

[pmid20332420-10] 10.0 ^10.1 ten Cate FJ, Soliman OI, Michels M, Theuns DA, de Jong PL, Geleijnse ML, Serruys PW (2010). "Long-term outcome of alcohol septal ablation in patients with obstructive hypertrophic cardiomyopathy: a word of caution". Circulation. Heart Failure. 3 (3): 362–9. doi:10.1161/CIRCHEARTFAILURE.109.862359. PMID 20332420. Retrieved 2012-02-11. Unknown parameter |month= ignored (help)

[pmid16938597-11] 11.0 ^11.1 Geddes LA, Roeder RA, Rundell AE, Otlewski MP, Kemeny AE, Lottes AE (2006). "The natural biochemical changes during ventricular fibrillation with cardiopulmonary resuscitation and the onset of postdefibrillation pulseless electrical activity". Am J Emerg Med. 24 (5): 577–81. doi:10.1016/j.ajem.2006.01.030. PMID 16938597.

[pmid2546233-12] Stueven HA, Aufderheide T, Waite EM, Mateer JR (1989). "Electromechanical dissociation: six years prehospital experience". Resuscitation. 17 (2): 173–82. PMID 2546233.

[pmid10869921-13] Peppriell JE, Bacon DR (2000). "Acute abdominal compartment syndrome with pulseless electrical activity during colonoscopy with conscious sedation". J Clin Anesth. 12 (3): 216–9. PMID 10869921.

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