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pulseless electrical activity; electromechanical dissociation (PEA)

Classification: ECG electrical activity other than VF/VT 1) electromechanical dissociation 2) idioventricular rhythms 3) ventricular escape rhythms 4) bradyasystolic rhythm 5) postdefibrillation idioventricular rhythms Etiology: 1) hypovolemia 2) hypoxemia 3) cardiac tamponade 4) tension pneumothorax 5) hypothermia 6) massive pulmonary embolus 7) drug overdose 8) hyperkalemia 9) severe acidosis 10) massive acute myocardial infarction Special laboratory: - point-of-care ultrasound - lack of cardiac activity portends poor prognosis [5] Management: 1) assess for presence of pulse, begin CPR if no pulse - recheck for pulse after 2 minutes of CPR 2) cardiac monitor to assess rhythm 3) use Doppler to assess blood flow a) if blood flow, treat for severe hypotension b) if no blood flow continue CPR 4) establish IV access 5) intubate (IV access takes precedence over intubation) 6) consider possible causes & treat 7) epinephrine 1 mg IV push every 3-5 min - administration of 1st dose within 1 to 3 minutes [3] - longer time to epinephrine administration is associated with diminished survival in children with in-hospital cardiac arrest & pulseless electrical activity [4] 8) atropine no longer recommended [2] 9) adenosine may be used [2] 10) if no response a) high dose epinephrine * b) NaHCO3 if appropriate # * high dose epinephrine: 2-5 mg IV push every 3-5 min; 1 mg, 3 mg, 5 mg 3 minutes apart; 0.1 mg/kg every 3-5 min # NaHCO3 not indicated early in resuscitation, acidosis is generally secondary to inadequate ventilation, dose is 1 meq/kg IV followed by 0.5 meq/kg every 10 min

General

cardiac arrhythmia

References

  1. Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 180
  2. 2010 American Heart Association Guidelines for CPR and Emergency Cardiovascular Care Oct. 18, 2010 Comparison Chart of Key Changes http://www.heart.org/idc/groups/heart-public/@wcm/@ecc/documents/downloadable/ucm_317267.pdf
  3. Young K cites BMJ article For Cardiac Arrest with Nonshockable Rhythm, Quicker Epinephrine Is Better. Physician's First Watch, May 22, 2014 David G. Fairchild, MD, MPH, Editor-in-Chief Massachusetts Medical Society http://www.jwatch.org
  4. Andersen LW et al Time to Epinephrine and Survival After Pediatric In-Hospital Cardiac Arrest. JAMA. 2015;314(8):802-810. PMID: 26305650 http://jama.jamanetwork.com/article.aspx?articleid=2429714 - Tasker RC, Randolph AG Pediatric Pulseless Arrest With "Nonshockable" Rhythm. Does Faster Time to Epinephrine Improve Outcome? PMID: 26305646 JAMA. 2015;314(8):776-777
  5. Gaspari R et al. Emergency department point-of-care ultrasound in out-of- hospital and in-ED cardiac arrest. Resuscitation 2016 Sep 27 PMID: 27693280 http://www.resuscitationjournal.com/article/S0300-9572(16)30478-6/abstract