Pulseless Electrical Activity(PEA) occurs in about 30% of cardiac arrest cases. Given that it’s not a shockable rhythm, it has a very poor prognosis, especially when associated with acute myocardial Infarction(MI)(1). More recently, the term pseudo-PEA, is used for those patients where we can’t find an output by feeling for a pulse, but there may in fact be one, when we view the heart by echocardiography. More on this will follow in the next few blogs.
When confronted by the PEA patient, ACLS guidelines require us to quickly evaluate the potential cause by citing the H’s and T’s. I don’t know about you but I see people trying to think of them during an arrest and having trouble. In fact the literature shows that it is difficult during an arrest to remember them all(2), so you and I are not alone.
I personally have an approach that is as follows:
- Maximise oxygenation
- Give them fluid
- Could they be having a PE or MI or is there a cardiac tamponade?
- What’s their potassium doing?
- …..Then I’ve got to think of the others……..
That’s been my approach since I can remember.
Things have changed since these guidelines were produced. We now use echocardiography and certainly our appreciation of electrocardiographic tracings has much improved, yet neither ECG tracings nor echocardiography appear anywhere in these protocols.
In a 2014 paper, Littmann et al(3) proposed a new tool that simplified the approach to PEA by simply looking at the width of the QRS complex and dividing the causes based on QRS width.
- QRS duration < 0.12s (3 small squares)
- QRS duration > or = 0.12s
Narrow QRS <0.12s
This is usually caused by a mechanical problem due to an outflow obstruction.
The 4 most common causes are:
- Cardiac Tamponade
- Pulmonary Embolism
- Tension Pneumothorax
- Mechanical Hyperinflation
Using our bedside ultrasound we can look for the following:
- Collapsed right ventricle which indicates an obstruction to blood going to the heart and caused by:
- Tamponade
- Hyperinflation
- Pneumothorax
- Dilated Right Ventricle
- Pulmonary Embolism
Wide QRS > or = 0.12s
This is usually due to a metabolic problem or ischaemia and heart failure. This may be:
- Hyperkalaemia
- Sodium Channel Blocker Toxicity
- Cardiac Ischaemia
This approach doesn’t take into account hyperaemia, hypokalaemia, or hypoglycaemia, however the frequency of progression to PEA of these patients is very rare(4). The proposed approach doesn’t specifically use hypothermia or toxins but assumes that given the history of presentation, that these causes will be picked up.
How To Use This Approach
In A Narrow QRS Complex PEA
- Start Fluid- Normal Saline and be aggressive as these causes may respond to fluid.
The echocardiogram can give the rest of the solution
- If there is PE: Thrombolytics
- If there is over ventilation, disconnect
- If a Tension pneumothorax then decompress.
If A Wide QRS Complex PEA
- If Hyperkalaemia is suspected give NaHCO3 and Calcium
- If Na channel blockade is suspected, give NaHCO3
In Summary:
Please remember that this system is an academic proposal and as the author himself writes, there are some limitations, especially with patients with a pre-existing left bundle branch block or a massive PE, where the complexes may appear wide.
I like the approach because it makes me think differently and takes into account the very thing we are looking at throughout this whole scenario…the ECG trace.
References
- Nadkarni VM, Larkin GL, Peberdy MA, et al. First documented rhythm and clinical outcome from in-hospital cardiac arrest among children and adults. JAMA. 2006;295:50–57.
- Morgan R, Westmoreland C. Survey of junior hospital doctors’ attitudes to cardiopulmonary resuscitation. Postgrad Med J. 2002;78:413–415.
- Littmann L, Bustin DJ, Haley MW. A Simplified and Structured Teaching Tool for the Evaluation and Management of Pulseless Electrical Activity. Med Princ Pract 2014;23:1-6.
- Desbiens NA. Simplifying the diagnosis and management of pulseless electrical activity in adults: a qualitative review. Crit Care Med. 2008;36:391–396.
Associate Professor Peter Kas
Pulseless Electrical Activity – Resus
avgtrzpjqlf
vgtrzpjqlf http://www.go1zp0g336at234mh58mfcg5tw75s022s.org/
[url=http://www.go1zp0g336at234mh58mfcg5tw75s022s.org/]uvgtrzpjqlf[/url]
Very nice blog post. I certainly appreciate this site.
Keep writing!
Anti-Corrosion Chemical Pump
Diorディオールマフラー販売店
What a material of un-ambiguity and preserveness of valuable
know-how about unexpected feelings.
I’ve been browsing online more than 2 hours today, yet I
never found any interesting article like yours.
It is pretty worth enough for me. Personally, if all website owners
and bloggers made good content as you did, the
internet will be a lot more useful than ever before.
Whoa! This blog looks exactly like my old one! It’s on a completely different topic but it has pretty
much the same layout and design. Wonderful choice of colors!
My spouse and I stumbled over here from a different web page and
thought I might check things out. I like what I see so now i am following you.
Look forward to looking into your web page for a second time.
This information is invaluable. When can I find out more?
Every weekend i used to go to see this web site,
for the reason that i wish for enjoyment, for the reason that this this
web page conations truly pleasant funny information too.
Hi there i am kavin, its my first time to commenting anywhere, when i read this article i thought i could also make comment
due to this brilliant piece of writing.
Nice post. I learn something new and challenging on blogs I stumbleupon every
day. It’s always useful to read through content from other writers and
use a little something from their websites.
Today, while I was at work, my sister stole my iPad and tested to see if it can survive a forty foot drop, just so she can be
a youtube sensation. My iPad is now broken and she has 83 views.
I know this is entirely off topic but I had to share it with someone!
May I simply just say what a comfort to find a person that really knows what
they’re talking about on the net. You certainly understand how to bring an issue to light and make it important.
A lot more people must read this and understand this side of your story.
I can’t believe you aren’t more popular given that you definitely possess the
gift.
No matter if some one searches for his necessary
thing, thus he/she needs to be available that in detail,
thus that thing is maintained over here.
I couldn’t resist commenting. Perfectly written!
What’s up everybody, here every one is sharing these kinds
of knowledge, thus it’s pleasant to read this blog, and I used to visit this web
site all the time.
After going over a handful of the blog articles on your web
site, I honestly like your technique of blogging.
I saved it to my bookmark site list and will be checking back in the near
future. Please check out my website as well and tell me how you feel.
Hey there just wanted to give you a quick heads up. The words in your post seem to be running off the screen in Ie.
I’m not sure if this is a format issue or something to do with internet browser
compatibility but I thought I’d post to let you know.
The design and style look great though! Hope you get the issue solved soon. Thanks
Hello there! I could have sworn I’ve visited this website before but after going through
some of the posts I realized it’s new to me.
Anyhow, I’m certainly delighted I found it and I’ll be bookmarking it and checking
back frequently!
whoah this blog is fantastic i like reading your posts.
Keep up the great work! You already know, many persons are looking around for this information, you can help them greatly.
Great site. Lots of helpful information here.
I’m sending it to a few pals ans additionally sharing in delicious.
And naturally, thank you for your effort!
Hi there, after reading this remarkable article i am as well delighted to share my know-how here with colleagues.
Hey there would you mind letting me know which webhost
you’re using? I’ve loaded your blog in 3 completely different browsers and I
must say this blog loads a lot quicker then most.
Can you suggest a good web hosting provider at a fair price?
Many thanks, I appreciate it!
It’s awesome to go to see this site and reading the views of all friends about
this article, while I am also eager of getting
knowledge.
Hi, i think that i saw you visited my site thus i came to “return the favor”.I’m trying to find things to improve my site!I suppose its ok
to use some of your ideas!!
I’ve been exploring for a little for any high quality articles or blog posts
on this kind of area . Exploring in Yahoo I at last stumbled upon this site.
Reading this information So i’m glad to show that I’ve a very good
uncanny feeling I came upon just what I needed. I such a lot for
sure will make sure to don?t overlook this web site and give it a glance on a relentless basis.
ブランドStellaMcCartneyステラマッカートニーバッグコピー代引き
Air Operated Micro Diaphragm Pump
I’m not that much of a online reader to be honest but your blogs really nice, keep it up!
I’ll go ahead and bookmark your site to come back later.
Many thanks
Hello, Neat post. There is an issue with your website in web explorer, could test this?
IE nonetheless is the marketplace chief and a big section of other folks will pass over your excellent writing because of this problem.
I take pleasure in, cause I found just what I was taking a look for.
You’ve ended my four day long hunt! God Bless you man. Have a great day.
Bye
I loved as much as you will obtain carried out right here. The caricature is attractive, your authored material stylish.
nonetheless, you command get bought an nervousness over that
you want be delivering the following. unwell indubitably come more
earlier once more since precisely the similar nearly a lot often inside case you defend this hike.
Also visit my blog growing weed – Vicente –
ブランドBvlgariブルガリ指輪コピーN級品
Moving Crates
I just now wanted to thank you a lot more for that amazing site you
have created here. It’s full of ideas for those who are genuinely
interested in this particular subject, particularly this very post.
Your all actually sweet along with thoughtful of others in addition to the fact that reading
your site posts is a wonderful delight if you ask me.
And thats a generous present! Tom and I usually have excitement making use of your tips in what we have to do next
week. Our collection of ideas is a mile long and tips will be put to fine use.
Here is my web site – glowing skin
Thank you for the blog post. Thomas and I have already been saving for just a new publication on this theme and your blog post has made us all to save money.
Your opinions really answered all our concerns. In fact, more than what we had acknowledged in advance benefits of hemp seed oil the time we stumbled on your
fantastic blog. My partner and i no longer nurture doubts plus a
troubled mind because you have attended to our
needs right here. Thanks
Terrific paintings! That is the kind of info that should be shared around the internet.
Disgrace on the seek engines for no longer positioning this publish upper!
Come on over and talk over with my site . Thanks =)
Have a look at my page; low carb diet daily
I really like looking through a post that will make people think.
Also, thank you for permitting me to comment!
My webpage benefits of hemp seed oil
Hi friends, its enormous piece of writing concerning educationand entirely explained, keep it up all the time.
Hello, I enjoy reading through your article. I wanted to write a little comment to support
you.
My web site :: cleansing skin care – http://www.zichen.com/ –
I have read so many posts about the blogger lovers except this article is genuinely a good post, keep it up.
my homepage – skin care product
Greetings from Ohio! I’m bored to tears at work so I decided to browse your blog on my iphone
during lunch break. I enjoy the info you provide here and can’t wait to take
a look when I get home. I’m surprised at how fast your blog
loaded on my cell phone .. I’m not even using WIFI, just 3G ..
Anyhow, very good blog!
Feel free to surf to my site – growing cannabis seeds
My brother suggested I might like this blog.
He was totally right. This post truly made my day.
You cann’t imagine just how much time I had spent for this info!
Thanks!
Also visit my homepage amazing weight loss
Wonderful goods from you, man. I have bear in mind your stuff previous
to and you are simply too excellent. I really like what you
have got here, really like what you’re stating and the way through which you say it.
You make it entertaining and you continue to take care of to keep it smart.
I can not wait to learn much more from you. This is actually a wonderful web site.
my web-site fat loss diet
Link exchange is nothing else however it is just placing the other person’s weblog link eczema on feet (https://www.mhes.tyc.edu.tw/userinfo.php?uid=4134760) your page at
appropriate place and other person will also do similar in support of you.
Hi colleagues, how is everything, and what you want to say regarding this article, in my
view its really amazing for me.
my site … sexy lingerie
Thank you, I have just been searching for information approximately this
subject for a long time and yours is the greatest I’ve discovered so far.
But, what concerning the conclusion? Are you certain in regards to
the supply?
My web site … care routine (forum.m2clasic.ro)
My family all the time say that I am wasting my time here at
net, but I know I am getting experience daily by reading such good
articles.
Here is my website: sexual pleasure
Hey I know this is off topic but I was wondering if you knew of any widgets I could add to my blog that automatically
tweet my newest twitter updates. I’ve been looking for a plug-in like this for quite some time
and was hoping maybe you would have some experience with something
like this. Please let me know if you run into anything.
I truly enjoy reading your blog and I look forward to
your new updates.
my web site – hatched seeds require
Yay google is my world beater assisted me to find this
great site!
Also visit my website :: cyclical ketogenic diet
Hi my loved one! I wish to say that this article is awesome, nice written and include almost all significant infos.
I would like to look more posts like this .
Check out my web blog; weed indoorshave
When someone writes an post he/she keeps the idea
of a user in his/her brain that how a user can understand it.
Thus that’s why this paragraph is outstdanding.
Thanks!
Also visit my blog quality treatment
Hello! Would you mind if I share your blog
with my twitter group? There’s a lot of folks that I think would really enjoy your content.
Please let me know. Thanks
Also visit my web page :: seeds require; http://163.30.42.16,
We’re a group of volunteers and starting a brand new scheme in our community.
Your website provided us with helpful info to work on. You have performed a formidable process and our entire group will likely be thankful to you.
Here is my website: fisher f44
Hmm is anyone else experiencing problems with the pictures
on this blog loading? I’m trying to find out if its a problem on my
end or if it’s the blog. Any suggestions would be greatly appreciated.
Take a look at my blog talking dirty
Hi there, after reading this amazing piece of writing i am
too happy to share my knowledge here with colleagues.
my blog post natural libido pills
Great post. I was checking continuously this blog and I am impressed!
Very helpful information specially the last part 🙂
I care for such information a lot. I was seeking this certain information for a
long time. Thank you and best of luck.
Stop by my website; drug crime, Marquita,
I have to convey my passion for your kind-heartedness
in support of visitors who really need help with
your matter. Your very own commitment to getting the solution all over has
been unbelievably advantageous and has consistently
permitted many people like me to reach their endeavors.
Your invaluable guideline entails a whole lot
to me and far more to my colleagues. Thank you; from all of us.
Feel free to surf to my webpage: acne medication
Woh I your blog posts, bookmarked!
Here is my web blog; upper back pain
Hello everybody, here every one is sharing such experience, so it’s fastidious to read this blog, and I used
to go to see this webpage every day.
Hey! Do you know if they make any plugins to assist
with Search Engine Optimization? I’m trying to get my blog to rank for some targeted keywords
but I’m not seeing very good results. If you know of any please share.
Many thanks!
You made some really good points there. I checked on the net
for more information about the issue and found most people will go along with
your views on this website.
Hi there, just wanted to mention, I loved this article.
It was inspiring. Keep on posting!
What’s up, I read your blogs daily. Your humoristic style is awesome,
keep doing what you’re doing!
If some one wishes to be updated with most recent technologies then he must be pay a quick visit this website and be up to date
everyday.
I visited many web sites except the audio quality for audio songs present at this web page is in fact superb.
This is very attention-grabbing, You’re an excessively skilled blogger.
I’ve joined your feed and sit up for in quest of more of your wonderful post.
Additionally, I have shared your website in my social networks
What’s up i am kavin, its my first time to commenting anywhere, when i read
this post i thought i could also create comment due to this brilliant piece of writing.
I’m not that much of a internet reader to be honest but
your sites really nice, keep it up! I’ll go ahead and bookmark your site
to come back in the future. Many thanks
Good day! This is kind of off topic but I need some guidance from an established blog.
Is it tough to set up your own blog? I’m not very techincal but I can figure things out pretty fast.
I’m thinking about making my own but I’m not sure where to begin. Do you have any ideas or suggestions?
Appreciate it
Thanks for ones marvelous posting! I truly enjoyed reading it, you
will be a great author.I will be sure to bookmark your blog and definitely will come back very soon. I
want to encourage you to ultimately continue your great writing,
have a nice evening!
Your method of explaining everything in this paragraph is actually pleasant, every one can effortlessly know it, Thanks a lot.
That is a very good tip especially to those fresh to the blogosphere.
Simple but very precise info… Appreciate your sharing this one.
A must read article!
Pretty nice post. I just stumbled upon your blog and wished to say that I have
really enjoyed browsing your blog posts. After all I will be subscribing to your
feed and I hope you write again very soon!
Good day! I just want to offer you a big thumbs
up for the great info you have got here on this post.
I will be returning to your site for more soon.
If you wish for to obtain a good deal from this post
then you have to apply such strategies to your won blog.
We are a group of volunteers and opening a new scheme in our community.
Your web site offered us with valuable info to work on. You have
done a formidable job and our entire community will be grateful to you.
When someone writes an article he/she keeps the plan of a user
in his/her brain that how a user can be aware of it.
Therefore that’s why this piece of writing is great.
Thanks!
Nice weblog right here! Also your web site loads up fast!
What web host are you the usage of? Can I get your associate link in your host?
I desire my website loaded up as quickly as yours lol
Hi, Neat post. There is an issue along with your web site in web explorer,
could check this? IE nonetheless is the market chief and a good component of other people will omit your excellent writing because of this problem.
my website – sex pills
I pay a visit every day some websites and sites to read content,
however this weblog offers quality based posts.
Have you ever considered about including a little bit more than just your articles?
I mean, what you say is important and all. But just imagine if you added some great images or video clips to
give your posts more, “pop”! Your content is excellent but with pics and
videos, this website could certainly be one of the most
beneficial in its niche. Amazing blog!
ブランドコピー代引き
4-Amino-3-Chlorophenol Hydrochloride 52671-64-4
Licenced Battery Operated Lexus Car
コピー時計
Disperse Red 1
Cardiac Trigger Monitor 3000
日本国内最高級スーパーコピーブランド激安販売
Fast Food Delivery Electric Battery Box Truck
ブランド時計コピー
China Air Purifier
ブランドバッグコピー
Natural Toothbrush Bristles
12371-0H130
ブランド財布コピー
9 Gallon Portable Air Tank
IDC 2.54 Grey Flat Ribbon Cable
Carbon Steel Bluewhite Zinc Plated Drop in Anchor with Knurling
Battery Organizer And Tester
ブランドバッグコピー
スーパーコピーバッグ
Carbon Steel Pipe And Fittings
Food Grade Dish