PULSELESS ELECTRICAL ACTIVITY / PEA
ALL LEVELS
DESIGNATION OF CONDITION
Patient presenting in cardiac arrest with organized electrical activity noted on the cardiac monitor, but without corresponding pulses palpated. Determination and correction of underlying cause of the PEA may improve outcome. Specific problems which may cause PEA:
EMPHASIS ON PATIENT CARE
Effective CPR, management of associated conditions
1. Primary Management - Assess ABC’s and manage as indicated.
2. Initiate high quality team CPR
3. Insert advanced airway (follow Airway Management Procedure Guidelines).
4. Apply defibrillation electrodes and begin cardiac monitoring.
5. Transport the patient if ROSC, consider ALS intercept.
6. Secondary Management - History, physical exam, vital signs
AEMT
1. Consider placement of Supraglottic airway (LMA preferred), allowing no disruption of chest compressions during placement.
2. Initiate one or two large bore IV/ IO of an isotonic solution with 20mL/kg fluid bolus. Repeat as indicated.
3. Administer EPINEPHRINE See s\SPECIAL NOTE below.
PARAMEDIC
1. Consider placement of SGA, ETT Airway. DO NOT STOP CPR TO INTUBATE
2. Consider SODIUM BICARBONATE [1 mEq/kg] IV/IO, if tricyclic antidepressant overdose or metabolic acidosis is suspected.
3. Treat for any suspected reversible causes (identified in the designation of condition) within applicable scope of practice.
4. Contact medical direction for possible TOR order if no ROSC and the patient remains in asystole after 30 minutes of ALS resuscitative efforts. See Termination of Resuscitative Efforts Treatment Guidelines
5. In cases of PEA with end tidal CO2 levels in the 20-30 range consider “Pseudo-PEA” and select Push Dose Epinephrine in place of Epinephrine 1:10,000 boluses. 1 mg. 1:1,000 Epinephrine in 100 ml. and draw up 10 ml. Administer 0.5-1.0 ml. per minute as needed.
Hypovolemia Toxins
Hypoxia Tamponade (cardiac)
Hydrogen Ion (acidosis) Tension pneumothorax
Hyper-/hypokalemia Thrombosis (coronary and pulmonary)
Hypothermia.
EPINEPHRINE DOSING IN CARDIAC ARREST SPECIAL NOTES
Shortages of EPINEPHRINE 1:10,000 are necessitating alternate dosing for cardiac arrest patients. EPINEPHRINE administration in cardiac arrest patients is associated with improved ROSC rates but no dosing regimen has been shown to be superior in terms of ultimate survival. The following dosing regimens are acceptable in cardiac arrest patients when EPINEPHRINE 1:10,000 is unavailable or rationed. ET dosing is no longer an approved route.
1. AHA recommended dosing if EPINEPHRINE available: 1 mg. IV/IO q 3-5 minutes. No limitation on number of doses given.
2. EPINEPHRINE 1 mg. q 5-10 minutes IV/IO. No limitation on number of doses given.
3. EPINEPHRINE 1 mg. IV/IO followed by infusion.
a. Infusion: Mix 3 mg. (3 vials of 1 mg. 1:1,000) into a 1,000 cc bag of crystalloid solution and run so that bag is infusing throughout the 30 minute resuscitation.
4. EPINEPHRINE infusion only.
ALL LEVELS
DESIGNATION OF CONDITION
Patient presenting in cardiac arrest with organized electrical activity noted on the cardiac monitor, but without corresponding pulses palpated. Determination and correction of underlying cause of the PEA may improve outcome. Specific problems which may cause PEA:
EMPHASIS ON PATIENT CARE
Effective CPR, management of associated conditions
1. Primary Management - Assess ABC’s and manage as indicated.
2. Initiate high quality team CPR
3. Insert advanced airway (follow Airway Management Procedure Guidelines).
4. Apply defibrillation electrodes and begin cardiac monitoring.
5. Transport the patient if ROSC, consider ALS intercept.
6. Secondary Management - History, physical exam, vital signs
AEMT
1. Consider placement of Supraglottic airway (LMA preferred), allowing no disruption of chest compressions during placement.
2. Initiate one or two large bore IV/ IO of an isotonic solution with 20mL/kg fluid bolus. Repeat as indicated.
3. Administer EPINEPHRINE See s\SPECIAL NOTE below.
PARAMEDIC
1. Consider placement of SGA, ETT Airway. DO NOT STOP CPR TO INTUBATE
2. Consider SODIUM BICARBONATE [1 mEq/kg] IV/IO, if tricyclic antidepressant overdose or metabolic acidosis is suspected.
3. Treat for any suspected reversible causes (identified in the designation of condition) within applicable scope of practice.
4. Contact medical direction for possible TOR order if no ROSC and the patient remains in asystole after 30 minutes of ALS resuscitative efforts. See Termination of Resuscitative Efforts Treatment Guidelines
5. In cases of PEA with end tidal CO2 levels in the 20-30 range consider “Pseudo-PEA” and select Push Dose Epinephrine in place of Epinephrine 1:10,000 boluses. 1 mg. 1:1,000 Epinephrine in 100 ml. and draw up 10 ml. Administer 0.5-1.0 ml. per minute as needed.
Hypovolemia Toxins
Hypoxia Tamponade (cardiac)
Hydrogen Ion (acidosis) Tension pneumothorax
Hyper-/hypokalemia Thrombosis (coronary and pulmonary)
Hypothermia.
EPINEPHRINE DOSING IN CARDIAC ARREST SPECIAL NOTES
Shortages of EPINEPHRINE 1:10,000 are necessitating alternate dosing for cardiac arrest patients. EPINEPHRINE administration in cardiac arrest patients is associated with improved ROSC rates but no dosing regimen has been shown to be superior in terms of ultimate survival. The following dosing regimens are acceptable in cardiac arrest patients when EPINEPHRINE 1:10,000 is unavailable or rationed. ET dosing is no longer an approved route.
1. AHA recommended dosing if EPINEPHRINE available: 1 mg. IV/IO q 3-5 minutes. No limitation on number of doses given.
2. EPINEPHRINE 1 mg. q 5-10 minutes IV/IO. No limitation on number of doses given.
3. EPINEPHRINE 1 mg. IV/IO followed by infusion.
a. Infusion: Mix 3 mg. (3 vials of 1 mg. 1:1,000) into a 1,000 cc bag of crystalloid solution and run so that bag is infusing throughout the 30 minute resuscitation.
4. EPINEPHRINE infusion only.