a new pulseless electrical activity algorithm - r.e.b.e.l
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2015/5/19 A New Pulseless Electrical Activity Algorithm - R.E.B.E.L. EM - Emergency Medicine Blog
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A New Pulseless Electrical Activity
Algorithm
18 MayMay 18, 2015
Patients with pulseless electrical activity (PEA)account for almost 1/3 of cardiac arrest and even more troublesome is that the survival rate issignificantly worse than patients with shockable rhythms. Both the European and AmericanACLS guidelines stress the importance of quickly finding and addressing the cause of PEA.This is traditionally done with recalling the 5 to 6 Hs and Ts, but during cardiopulmonaryresuscitation it is difficult to recall all 13 causes of PEA by trying to recall this list. In 2014 areview article was published that was developed by several departments from the Carolinas
113 95 11 3 9 2 13
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2015/5/19 A New Pulseless Electrical Activity Algorithm - R.E.B.E.L. EM - Emergency Medicine Blog
http://rebelem.com/a-new-pulseless-electrical-activity-algorithm/ 2/8
Medical Center in Charlotte, NC that tried to simplify the diagnostic approach to PEA.
A New Simplified and Structured Method in the Evaluation
and Management of Pulseless Electrical Activity
What are the traditionally taught Hs and Ts of PEA?
*Hypoglycemia and trauma have been removed from the most recent ACLS guidelines.
What is the new diagnostic classification of PEA?
Step 1: Determine if the PEA is narrow (QRS duration
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2015/5/19 A New Pulseless Electrical Activity Algorithm - R.E.B.E.L. EM - Emergency Medicine Blog
http://rebelem.com/a-new-pulseless-electrical-activity-algorithm/ 3/8
Point of care ultrasound (POCUS) can quickly aid in identification of mechanical causes ofPEA. A collapsed right ventricle suggests an inflow obstruction (i.e tamponade, pneumothorax,or hyperinflation) whereas a dilated right ventricle indicates outflow obstruction (i.e. Pulmonaryemobolism).
Most Common Causes:
Cardiac TamponadeTension PneumothoraxMechanical HyperinflationPulmonary Embolism
Treatment:
Aggressive intravenous fluid administrationCardiac Tamponade > PericardiocentesisTension Pneumothorax > Needle decompressionMechanical Hyperinflation > Adjust ventilatorPulmonary Embolism > Thrombolytic therapy
Wide-Complex PEA
This typically suggests a metabolic or toxic ingestion problem. Hyperkalemia and/or sodiumchannel blocker toxicity.
Treatment:
Hyperkalemia > Intravenous calcium chloride or gluconateHyperkalemia or Sodium Channel Blocker Toxicity > Sodium bicarbonate
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2015/5/19 A New Pulseless Electrical Activity Algorithm - R.E.B.E.L. EM - Emergency Medicine Blog
http://rebelem.com/a-new-pulseless-electrical-activity-algorithm/ 4/8
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Discussion:
This new classification system of PEA has 3 potential benefits compared to the traditionalACLS 5 Hs and 5 Ts
1. Rather than randomly listing 10 13 causes of PEA by memorizing the Hs and Ts, thisnew algorithm categorizes the possible causes of PEA based on the easy finding of QRScomplexes being narrow or wide.
2. Within each category there is a marked decrease in the etiologies one has to rememberand is based on the etiologies with the highest likelihood and clinical relevance.
3. This algorithm also provides specific treatment recommendations that are based on theinitial QRS morphology.
What are the limitations of this classification system?
This algorithm does not apply to the trauma settingThis algorithm has not been systematically tested for inclusiveness or resuscitationoutcomesNarrow-complex PEA almost always indicates a mechanical cause, but occasionallymechanical causes can present with wide-complex PEA. (i.e. pre-existing bundle branchblocks, massive PE causing RBBB, and acute MI causing new LBBB)
Conclusion: Using the new classification system of PEA simplifies the working differential and
initial treatment approach in conjunction with bedside ultrasound, however this strategy has notbeen tested systematically, tested for resuscitation outcomes, and caution should be usedbefore implementing this algorithm until further studies are performed in the clinical setting.
References:
1. Littmann et al. A Simplified And Structured Teaching Tool for the Evaluation andManagement of Pulseless Electrical Activity. Med Princ Pract 2014; 23: 1 6. PMID:23949188
Post Peer Reviewed by: Anand Swaminathan, MD (Twitter: @EMSwami)