CODE MANAGEMENTPulseless Electrical Activity (PEA)

PEAOBJECTIVES:

• Define PEA

• Narrow Complex PEA

• Wide Complex PEA

• ACLS Cardiac Arrest Algorithm for PEA

• ACLS Post Cardiac Arrest Care Algorithm

PEAWhat is PEA?

• PEA is defined as, “…spontaneous organized cardiac electric activity in the absence of blood flow sufficient to maintain consciousness and absence of a rapid spontaneous return of adequate organ perfusion and consciousness.” Circulation. 2013;128:2532-2541

• https://doi.org/10.1161/CIRCULATIONAHA.113.004490

PEAWhat can cause PEA?

• PEA is the result of underlying pathological process.

What is the goal of care?

• Resolution of the ‘cause’ or ‘problem’ is essential for ROSC.

PEA

• In ACLS the Hs & Ts are used to describe possible causes of a PEA arrest.

• However, the patient’s history and EKG can help guide interventions.

• Furthermore, for admitted hospital patients there are specific common causes of a PEA arrest (Littman et al).

PEANarrow

QRS

Cardiac Tomponade

• Pericardialcentesis

Pneumothorax• Needle

Decompression• Chest Tube

Massive PE• TPA 50-100mg IV

Volume Loss• IV Fluids• Blood Products• Massive Transfusion

Wide QRS

Hyperkalemia•D50W amp + Hum “R” 5-10 units

•NaHCO3- IV•CaCl IV

Acidosis• Increase ventilation

(↓CO2)• NaHCO3- IV

MI• Cath Lab• TNK

Toxins• Specific antidote• CCB / Beta Blocker /

TCA

PEAWhat do I need to know?

• You do not shock PEA• CPR 30:2 (minimize interruptions)• Epinephrine 1mg IV or IO q3-5 minutes• Atropine 0.5-1mg IV or IO (in rare

cases)• Fix the problem!• If ROSC → Post Cardiac Arrest

Algorithm• If VF / VT → VF / VT Algorithm

PEA

PEAWhat happens if we achieve ROSC?

• Prepare to manage Post Cardiac Arrest Syndrome.

• Occurs with the return of spontaneous circulation.

• Ischemia and reperfusion injury can cause vasodilation (low BP).

• Cardiac dysfunction and pump failure (dilated cardiomyopathy).

• Post cardiac arrest brain injury.

• Severity depended on duration of code and patient history.

PEA

How do I manage Post Cardiac Arrest Syndrome?

• Airway management• Sedation• Levophed Infusion• Antiarrhythmic Agents• Labs / CXR / CT• Transfer to ICU, OR, or Cath

Lab.• Consider cooling the patient

PEAReferences:

ACLS 2015 PEA and Post Cardiac Arrest guidelines

CC 90-015 – D http://policy.nshealth.ca/Site_Published/DHA9/document_render.aspx?documentRender.IdType=6&documentRender.GenericField=&documentRender.Id=53045

Pulseless Electrical Activity, Circulations, 2013;128;2532-2541 http://circ.ahajournals.org/content/128/23/2532.short

A Simplified and Structured Teaching Tool for the Evaluation and Management of Pulseless Electrical Activity, Medical Principals & Practice, 2014;23:1-6 https://www.karger.com/Article/FullText/354195

Post Cardiac Arrest Syndrome A Review of Therapeutic Strategies, Circulation, 2011;123:1428-1435. http://circ.ahajournals.org/content/123/13/1428