Pulseless Arrest Algorithm for Managing Pulseless Electrical Activity (PEA)

Using the Pulseless Arrest Algorithm for Managing PEA

Patients with PEA have poor outcomes. Their best chance of returning to a perfusing rhythm is through the quick identification of an underlying reversible cause and correct treatment. As you use the algorithm to manage the PEA patient, remember to consider all the H's and T's, particularly hypovolemia, which is the most common cause of PEA. Also look for drug overdoses or poisonings.

Begin with the primary survey to assess the patient's condition:

  1. Tap the patient on the shoulder and ask, "Are you all right?"
  2. If the patient does not respond, call for help.
  3. Give 2 minutes (5 cycles) of CPR before leaving patient to call for help.
  4. Open airway.
  5. Listen, check for breathing. Give 2 breaths that make the chest rise.
  6. Check for a pulse.
  7. If the patient does not have a pulse or any other signs of life, begin CPR, 30 compressions to 2 respirations. (Push hard and fast--100/minute. Release chest completely.)
  8. Start an IV.
  9. Begin oxygen.
  10. Attach a monitor.
  11. Assess rhythm in less than 10 seconds.
    • Too fast or too slow?
    • Regular or irregular?
    • Wide or narrow QRS complex?
  12. Resume CPR. Check rhythm every 2 minutes (after 5 cycles of CPR)
  13. ECG waves seen? Yes.

Follow the ACLS Pulseless Arrest Algorithm.

The algorithm is divided into two arms: one for VT/VT and one for PEA and asystole. A patient with a rhythm that is not shockable requires treatment listed on the PEA or asystole side of the algorithm.

  1. Check the rhythm. It is not shockable.
  2. Resume CPR (5 cycles). During CPR, give the patient epinephrine or vasopressin.
    1. If the patient's rate is slow, consider giving atropine.
    2. Assess the patient's rhythm again. If rhythm is still not shockable, resume CPR (5 cycles).
    3. During CPR, search for and treat possible treatable causes (H's and T's in Figure 1).
    4. Check pulse. No pulse is felt.
    5. Continue searching for reversible causes.
    6. Continue CPR.
    7. Check pulse. If there is a pulse and the rhythm is organized, begin post-resuscitation care.

Two management priorities are maintaining high quality CPR and searching simultaneously for a treatable cause of the patient's PEA. Stop CPR only when absolutely necessary for pulse and rhythm checks. Establishing IV/IO access is a priority over advanced airway management. If an advanced airway is placed, change to continuous chest compressions without pauses for breaths. Give 8 to 10 breaths per minute and check rhythm every 2 minutes.