Pulseless Electrical Activity ( PEA ) is confusing! The diagnosis and treatment of PEA is bogged down by terminology and misunderstandings. Spurred by a recent interview I did with Anton Helman of EM Cases, I lay down some of my thoughts on PEA here.
The last time I discussed these issues was 5 years ago with Zack and Joe on EDECMO 13.
PEA Progression to ROSC
POCUS Pulse
Narrow / Wide doesn't Work
Rory breaks it down on the CCnerd in a post about QRS size in PEA.
What to Do if You Have Compressions/POCUS Pulse but No BP
Updates
More on PEA on the EM Cases Blog – I speak with Anton Helman on the topic
The Right Heart being Big doesn't mean PE during Arrest (from Ultrasound Podcast)
What is an acceptable BP to not do CPR?
(Crit Care 2014;18:719)
More on EMCrit
- EMCrit #235 – Cardiac Arrest Science with Zack Shinar
- Podcast 261 – Thrombolysis during Cardiac Arrest
- Podcast 125 – The New Intra-Arrest (Cardiac Arrest Management)
Additional Resources
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What do you think about radial arterial line instead of femoral? After lots of experience with peripheral IVs, I find placing radial arterial lines to be quicker than femoral.
it is ok, but there will be discrepancies between central and peripheral art in the setting of enormous epi doses, would recommend central
I have had a lot of nursing support with the cardiac arrest A-line. I feel it allows for less time with compression pauses and everyone in the room can see the pulse instead of relying on someones nervous fingers to feel it.. Our ED nurses recently had a special class on A-line setups and there seems to be total buy-in. The axillary A-line, that I learned how to do recently, has been very easy to do during cardiac arrest, especially with a 4-0 french micro-puncture kit. Thanks for all of the information, love the content!
I think the A-line is the greatest thing for hemodynamic monitoring during a code. It’s definitely nerve racking when there’s a “questionable pulse”.. do I feel it or no?….., then everyone is trying feel for a pulse and using up precious time. A- lines are definitely nurse approved!
yep, love the axillary as well. we go femoral b/c some of these pts will be ECMO candidates.
Scott, dare I say your thoughts on this are trending back to the area code of (gasp) Electromechanical Dissociation (EMD)? When I started in early January of 1999, although in its own agonal rhythm, it was still taught at least as the base concept. If you think about it physiologically, when there is still an organized rhythm, voltage and ionic gradients are still being maintained across the pacemaker cells, the conduction system, and the cardiomyocytes. This requires active transport of ions with ATP, and enzyme activity that also requires ATP or GTP. In order to get ATP/GTP, you need an… Read more »
Dave, thanks for commenting! We require full names if you want your comments to remain up on the site.
EMD is equivalent to PRES–which is likely equivalent to asystole. Most of these patients will die. EMD was actually a much better term than what we have now. EMD would be PRES. PEA would be PREM. ? and problem is what to cause a patient with a pulse (esp. a pocus pulse) and yet an insufficient BP to sustain perfusion. Calling these pts ROSC sends them down the wrong road.
Sorry Scott about the full name. It’s here in this comment. If we classify EMD-esque (PRES) as “asystole” – which literally means “without systole”, but has come to colloquially represent “no electrical activity”, will we not introduce confusion? Once there is no electrical activity, then ATP, ionic gradients, and active transport has stopped. It’s over. As I said if there is some organized electrical activity as in “PEA”, then there is enough ATP, oxygen, and ionic gradients to maintain that activity. Those cells have enough of what is needed to keep going. The rest of the body… not so much… Read more »
Scott,
I love your points about a perfusion-compatible BP. I wonder if in this respect we sometimes have delayed treatment of arrest because of A-lines. The tracing will show pulsatility for a long, long time after precipitous hypotension occurs
What do you think about this? I’ve certainly started compressions in patients with BP 35/25 – generally with MAP < 40 as I feel that's about the point I cannot trust a pressors bolus anymore.
map of 40 is a patient in or about to arrest. immediate Rx (push-dose, etc.) or cpr. They prob need the cpr to circulate the push-dose.
This is why I think when we’re messing around searching for a pulse or seeing if there’s a good pressure with that pulse, I think we should be starting IV infusion pressors until we have a bp that says otherwise. I feel that early use of IV infusion pressors could reduce the need for high doses of epi with false “PEAs” and the time of hypotension in ROSC patients. Thanks,
Pete
you lost me–have you listened to the podcast? Mentioned that norepi should be infusing in the background on all PEAs (all arrests actually)
Scott, are you giving high-dose epi in conjunction with nor-epi? I have always felt that high-dose epi is “robbing Peter to Pay Paul”. That is, the increase in contractility of the heart and then the increase in vascular tone to increase blood pressure seems to come at the price of possibly lower brain perfusion. We know epi helps achieve ROSC, but really doesn’t improve survival to discharge. By increasing contractility of the heart and increasing vascular tone, the SHORTEST fluid circuit is that of the left-ventricle out to the aorta, then to the coronary arteries, and then back around. Up… Read more »
Do you think any pulse check should be done at all if there is not a significant change in rhythm or rise in etco2?
Does US pulse check bring anything to the table prehospital or pre art line in the ED? If there is a perfusion capable rhythm and POCUS pulse or high etco2 what pressor dose are you starting with and how are you titrating it if you dont have an art line?