Pulseless Electrical Activity (PEA)

Considerations

• Is there a DNR?
• Review list of reversible causes (listed at bottom)

First Steps

• Call for code cart/defibrillator
• Apply monitor, get BVM with high flow O₂ attached, Establish IV [2^nd or 3^rd staff member to do this while CPR being performed]
• If out of hospital, activate EMS
• If in hospital, activate code team

If resuscitative efforts indicated

1. Open airway, give breath, start CPR
2. 5 Cycles of High Quality CPR (each cycle is 30 compressions then 2 breaths via BVM). CPR to continue uninterrupted until efforts cease or resuscitation successful.
3. Once IV is established, administer epinephrine or vasopressin [dosing below]. Atropine for Bradycardic PEA [dosing below].
   
   Epinephrine Dosing
   1 mg IVP or 2-2.5 mg ETT administered every 3-5 minutes until efforts cease or are successful (IV preferred).
   
   Vasopressin Dosing
   40 units IVP (may replace either 1^st or 2^nd dose of epinephrine with vasopressin if desired). If vasopressin used, next dose of epinephrine is 10 minutes after vasopressin.
   
   Atropine Dosing
   1 mg IVP (preferred) or 2-3 mg ETT administered every 3-5 minutes until maximum cumulative IV dose of 3mg (if given IV).
4. After EVERY 5 cycles of CPR [1 cycle = 30 compressions then 2 breaths (approx 2 minutes)] check rhythm and pulse.
5. Place advanced airway after initial 5 cycles of CPR[secure tube, confirm placement by breath sounds, visualization of cords, CO₂ monitor or esophageal detector device]. Once advanced airway placed, give 8-10 breaths/minute and provide continuous CPR (no pausing for breaths).
6. Carefully review and consider treatment for any reversible cause.
   
   Reversible Causes of PEA
   • Hypovolemia such as severe dehydration or massive hemorrhage
   • Hypoxia
   • Hypothermia
   • Myocardial Infarction or Pulmonary Embolus
   • Trauma such as tension pneumothorax, tamponade, aortic rupture
   • Poisoning such as beta blockers, TCA's, Digoxin
   • Metabolic causes such as hyperkalemia, hypokalemia, acidosis
   • Hypoglycemia
   • Cardiac Tamponade

Source: Circulation 2005;112. 2005 AHA Guidelines for CPR and ECC.