Version control: This document is current with respect to the latest 2016 American Heart Association® Guidelines for CPR and ECC. These guidelines are current until they are replaced on October 2020. If you are reading this page after October 2020, please contact ACLS Training Center at firstname.lastname@example.org for an updated document.
Patients with Pulseless Electrical Activity or 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:
- PEA occurs when you see a rhythm on the monitor that would normally be associated with a pulse, however the patient is pulseless.
- The rhythm can be anything, at any heart rate
- There is something preventing the heart from generating a pulse, such as being empty (hypovolemia) something pushing against it (Tamponade)
- Reassess the patient frequently for the return of pulses
Follow the ACLS Pulseless Arrest Algorithm
- Begin CPR as soon as pulselessness is recognized. Continue CPR at a rate of 100 to 120 per minute throughout the resuscitation without interruptions of more than 10 seconds to evaluate for pulses.
- Compressors should be switched every 2 minutes to ensure efficacy of compressions
- Ventilate the patient using a Bag Valve Mask (or advanced airway if already in place) at a rate of 10 per minute
- Waveform capnography should be utilized to monitor efficacy of compressions (should generate at least 10) and the return of pulses (will cause an increase in capnography to 40)
- Obtain IV/IO access
- Administer Epinephrine 1 mg IV/IO every 3–5 minutes
- Find and treat underlying causes.
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 10 breaths per minute and check rhythm every 2 minutes.
As soon as an underlying cause is identified, it should be treated. For example, if hypovolemia is identified as a possible cause of cardiac arrest, volume replacement should be started promptly. If tamponade, pericardiocentesis should occur rapidly. Without the treatment of the cause of arrest, neuro intact survival becomes unlikely.