COMMENTARY

The Most Life-Saving Emergency Medicine Articles of 2014

Amal Mattu, MD

Disclosures

December 19, 2014

Pulseless Electrical Activity

A Simplified and Structured Teaching Tool for the Evaluation and Management of Pulseless Electrical Activity
Littmann L, Bustin DJ, Haley MW
Med Princ Prac. 2014;23:1-6

Pulseless electrical activity (PEA) is the presenting rhythm in up to one third of all cases of cardiac arrest. Unlike ventricular fibrillation/pulseless ventricular tachycardia or asystole, however, advanced cardiac life support guidelines do not provide a "one-size-fits-all" treatment algorithm for PEA. Instead, providers are encouraged to remember a large differential of potential diagnoses, rapidly determine the exact diagnosis, and treat accordingly. Unfortunately, even mnemonics, such as the traditional "H's and T's," are complicated and difficult to remember in a tense clinical scenario.

The authors of this article have provided a much-needed, simple approach to the evaluation and management of PEA using nothing more than an ECG or rhythm strip and bedside ultrasound. The first step is to simply decide whether the patient has a narrow or wide QRS morphology. A narrow QRS is almost always associated with a right ventricular inflow (insufficient preload) or outflow (obstructive process) problem. A simple differential would include tamponade, tension pneumothorax, lung hyperinflation, pulmonary embolism, hypovolemia/hemorrhage, or myocardial infarction with myocardial rupture. Step two involves using a bedside ultrasound to distinguish between these causes. The ultrasound in these cases will generally show a hyperdynamic heart. The treatment for these patients involves fluid administration and managing the underlying diagnosis found on ultrasound.

For patients with a wide QRS morphology, the differential becomes one of severe metabolic or severe left ventricular dysfunction, such as hyperkalemia, sodium-channel blocker toxicity, or pump failure. Step two, use of the bedside ultrasound, is likely to demonstrate severe hypokineses or akinesis of the left ventricle. Empiric treatment for these patients involves calcium and sodium bicarbonate; and if an acute myocardial infarction is suspected, the patient needs inotropes and immediate catheterization.

The authors indicate that a few of the traditionally taught etiologies that are not addressed in this algorithm, such as hypoglycemia, hypoxia, and hypokalemia, are actually not supported by the literature as causes of PEA. This two-step algorithm involving ECG and ultrasound assessment is a simple and effective approach to a very common type of cardiac arrest.

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