Pulseless Electrical Activity

Confirm unresponsiveness, absent normal breathing, and no definite central pulse, then activate the resuscitation response and begin high-quality CPR. PEA is nonshockable; continue CPR rather than delivering a shock. Reassess rhythm and pulse at scheduled pauses, and switch to the shockable-arrest pathway only if ventricular fibrillation or pulseless ventricular tachycardia appears. PubMed+1PubMedSingapore Advanced Cardiac Life Support Guidelines 2021PubMedPulseless Electrical Activity and Asystole During In-Hospital Cardiac Arrest: Disentangling the ‘Nonshockable’ Rhythms

Obtain IV or IO access and administer epinephrine as early as possible in the nonshockable-arrest pathway. Epinephrine is recommended for cardiac arrest; high-dose epinephrine is not recommended routinely. Continue to search for and treat the precipitant during CPR rather than waiting for repeated rhythm checks. PubMed+1PubMedPulseless Electrical Activity and Asystole During In-Hospital Cardiac Arrest: Disentangling the ‘Nonshockable’ RhythmsACC2023 AHA Focused Update on Adult ACLS: Key Points - American College of Cardiology

Assign one clinician to a focused reversible-cause screen each cycle: prearrest trajectory, witnessed collapse versus respiratory deterioration, trauma or procedure, dialysis or renal failure, toxin exposure, anticoagulation, chest pain, known venous thromboembolism, severe asthma or obstructive lung disease, and hypothermic exposure. The Hs and Ts remain the core differential: hypovolemia, hypoxia, acidosis, potassium disorder, hypothermia, tension pneumothorax, tamponade, toxins, pulmonary or coronary thrombosis. PubMed+1PubMedAdvanced Cardiac Life Support (ACLS) - StatPearls - NCBI BookshelfPubMedPulseless Electrical Activity - StatPearls - NCBI Bookshelf

Narrow-complex PEA more often indicates a mechanical obstruction to forward flow, particularly tamponade, tension pneumothorax, mechanical hyperinflation, or pulmonary embolism. In a patient with abrupt collapse, distended neck veins, chest trauma, invasive thoracic procedure, obstructive lung disease, or severe dyspnea before arrest, prioritize a mechanical cause while maintaining CPR. PubMedPubMedA Simplified and Structured Teaching Tool for the Evaluation and Management of Pulseless Electrical Activity - PMC

Wide-complex PEA more often suggests a metabolic cause, particularly potassium derangement, severe acidosis, or sodium-channel-toxic exposure. Obtain targeted history from staff, family, medication records, dialysis records, and the prearrest ECG; use an immediately available blood gas and electrolyte measurement to direct correction when feasible without delaying resuscitation. PubMedPubMedA Simplified and Structured Teaching Tool for the Evaluation and Management of Pulseless Electrical Activity - PMC

Do not let QRS morphology exclude other diagnoses. Pulmonary or coronary thrombosis, profound hypoxia, hemorrhagic hypovolemia, hypothermia, and toxicologic causes may present with variable electrical patterns, so the working diagnosis must be revised with each new bedside finding. PubMed+2PubMedAdvanced Cardiac Life Support (ACLS) - StatPearls - NCBI BookshelfPubMedPulseless Electrical Activity - StatPearls - NCBI BookshelfPubMedA Simplified and Structured Teaching Tool for the Evaluation and Management of Pulseless Electrical Activity - PMC

Integrate focused cardiac and thoracic POCUS only during an already planned rhythm or pulse check. In PEA, ultrasound can identify findings that support tamponade, massive pulmonary embolism, or hypovolemia and can help distinguish pseudo-PEA from true absence of cardiac mechanical activity. ScienceDirect+2ScienceDirectRecognition and Management of Pseudo-Pulseless ...PubMedPulseless Electrical Activity - StatPearls - NCBI BookshelfPubMedA Simplified and Structured Teaching Tool for the Evaluation and Management of Pulseless Electrical Activity - PMC

Treat POCUS as a decision aid, not an isolated prognosis test. In nonshockable arrest, focused ultrasound may provide etiologic and prognostic information, but rapid recognition and treatment of reversible causes remain the purpose of imaging during resuscitation. ScienceDirect+1ScienceDirectIs point-of-care ultrasound a reliable predictor of outcome during atraumatic, non-shockable cardiac arrest? A systematic review and meta-analysis from the SHoC investigatorsPubMedPulseless Electrical Activity - StatPearls - NCBI Bookshelf

Interpret ETCO2 trends in their physiologic context. Ventilation rate, compression depth, airway type, and sex affect absolute values; in one out-of-hospital manual-CPR cohort, standardized ETCO2 was higher with ROSC than without ROSC, and ETCO2 trajectory differed before ROSC versus non-ROSC. A low or downward trend should first prompt correction of CPR and ventilation delivery rather than termination based on a single measurement. ScienceDirectScienceDirectStandardisation facilitates reliable interpretation of ETCO2 during manual cardiopulmonary resuscitation

Epinephrine is the routine vasoactive medication in PEA cardiac arrest; administer it early after IV/IO access is obtained. Vasopressin alone or combined with methylprednisolone may be considered in combination with epinephrine, but it is not a substitute for epinephrine. ACCACC2023 AHA Focused Update on Adult ACLS: Key Points - American College of Cardiology

Do not reflexively administer calcium, sodium bicarbonate, or magnesium in undifferentiated PEA. Calcium is appropriate as an adjunct when the presentation suggests hyperkalemia, hypermagnesemia, or calcium-channel-blocker overdose; listed IV/IO doses are calcium chloride 10% 5-10 mL or calcium gluconate 10% 15-30 mL. PubMed+1PubMedPulseless Electrical Activity - StatPearls - NCBI BookshelfACC2023 AHA Focused Update on Adult ACLS: Key Points - American College of Cardiology

Consider extracorporeal CPR for refractory arrest only in systems with appropriate equipment and trained staff. ECPR is a systems-dependent escalation, not a substitute for prompt conventional ACLS and immediate treatment of reversible causes. ACCACC2023 AHA Focused Update on Adult ACLS: Key Points - American College of Cardiology

Obtain a 12-lead ECG promptly after ROSC to guide coronary evaluation. Perform emergent coronary angiography for patients with suspected coronary cause and ST-segment elevation; angiography is also reasonable without ST elevation when the likelihood of significant coronary artery disease and potential benefit from revascularization are high. PubMed+1PubMedAdvanced Cardiac Life Support (ACLS) - StatPearls - NCBI BookshelfACC2023 AHA Focused Update on Adult ACLS: Key Points - American College of Cardiology

Normalize oxygenation, ventilation, and glucose control after ROSC, and provide lung-protective ventilation. Continue the etiologic workup initiated during arrest, including targeted assessment for pulmonary embolism, tamponade, tension pneumothorax, toxic exposure, electrolyte abnormality, hemorrhage, or hypoxic respiratory failure. PubMedPubMedAdvanced Cardiac Life Support (ACLS) - StatPearls - NCBI Bookshelf

Treat clinically evident seizures after ROSC. For patients who do not follow commands, EEG may be used to detect seizures; routine seizure prophylaxis is not recommended. In patients with spontaneous hypothermia who remain unresponsive to verbal commands, do not routinely rewarm faster than 0.5°C per hour. ACCACC2023 AHA Focused Update on Adult ACLS: Key Points - American College of Cardiology