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 May
May 18, 2015
113

95

11

13

Patients with pulseless electrical activity (PEA)

account for almost 1/3 of cardiac arrest and even more troublesome is that the survival rate is
significantly worse than patients with shockable rhythms. Both the European and American
ACLS 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 cardiopulmonary
resuscitation it is difficult to recall all 13 causes of PEA by trying to recall this list. In 2014 a
review article was published that was developed by several departments from the Carolinas
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2015/5/19

A New Pulseless Electrical Activity Algorithm - R.E.B.E.L. EM - Emergency Medicine Blog

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 <0.12) or wide (QRS duration
0.12) simply by looking at the telemetry monitor
Step 2: Narrow-complex PEA is generally due to mechanical problems caused by right
ventricular inflow or outflow obstruction
Step 3: Wide-complex PEA is typically due to metabolic problems, or ischemia and left
ventricular failure

Narrow-Complex PEA
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A New Pulseless Electrical Activity Algorithm - R.E.B.E.L. EM - Emergency Medicine Blog

Point of care ultrasound (POCUS) can quickly aid in identification of mechanical causes of
PEA. A collapsed right ventricle suggests an inflow obstruction (i.e tamponade, pneumothorax,
or hyperinflation) whereas a dilated right ventricle indicates outflow obstruction (i.e. Pulmonary
emobolism).
Most Common Causes:
Cardiac Tamponade
Tension Pneumothorax
Mechanical Hyperinflation
Pulmonary Embolism
Treatment:
Aggressive intravenous fluid administration
Cardiac Tamponade > Pericardiocentesis
Tension Pneumothorax > Needle decompression
Mechanical Hyperinflation > Adjust ventilator
Pulmonary Embolism > Thrombolytic therapy

Wide-Complex PEA
This typically suggests a metabolic or toxic ingestion problem. Hyperkalemia and/or sodium
channel blocker toxicity.
Treatment:
Hyperkalemia > Intravenous calcium chloride or gluconate
Hyperkalemia or Sodium Channel Blocker Toxicity > Sodium bicarbonate

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A New Pulseless Electrical Activity Algorithm - R.E.B.E.L. EM - Emergency Medicine Blog

Discussion:
This new classification system of PEA has 3 potential benefits compared to the traditional
ACLS 5 Hs and 5 Ts
1. Rather than randomly listing 10 13 causes of PEA by memorizing the Hs and Ts, this
new algorithm categorizes the possible causes of PEA based on the easy finding of QRS
complexes being narrow or wide.
2. Within each category there is a marked decrease in the etiologies one has to remember
and is based on the etiologies with the highest likelihood and clinical relevance.
3. This algorithm also provides specific treatment recommendations that are based on the
initial QRS morphology.

What are the limitations of this classification system?

This algorithm does not apply to the trauma setting
This algorithm has not been systematically tested for inclusiveness or resuscitation
outcomes
Narrow-complex PEA almost always indicates a mechanical cause, but occasionally
mechanical causes can present with wide-complex PEA. (i.e. pre-existing bundle branch
blocks, 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 not
been tested systematically, tested for resuscitation outcomes, and caution should be used
before 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 and
Management of Pulseless Electrical Activity. Med Princ Pract 2014; 23: 1 6. PMID:
23949188
Post Peer Reviewed by: Anand Swaminathan, MD (Twitter: @EMSwami)

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