Using the Pulseless Arrest Algorithm for Managing PEA

Version control: This document is current with respect to drug indications in 2010 American Heart Association Guidelines for CPR and ECC. These guidelines are current until they are replaced on March 2016. If you are reading this page (printed or online) after March 2016, please contact ACLS Training Center at for an updated document.

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. Pulseless Electrical Activity (PEA) occurs when you see a rhythm on the monitor that would normally be associated with a pulse, however the patient is pulses.

  2. The rhythm can be anything, at any heart rate

  3. There is something preventing the heart from generating a pulse, such as being empty (Hypovolemia) something pushing against it (Tamponate)

  4. Re-assess the patient frequently for the return of pulses

Follow the ACLS Pulseless Arrest Algorithm

  1. Begin CPR as soon as pulselessness is recognized. Continue CPR at a rate of 100/min throughout the resuscitation without interuptions of more than 10 seconds to evaluate for pulses.

  2. Compressors should be switched every 2 minutes to ensure efficacy of compressions

  3. 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)

  4. Obtain IV/IO access

  5. Administer Epinephrine 1 mg IV/IO every 3-5 minutes

  6. 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 8 to 10 breaths per minute and check rhythm every 2 minutes.