Brief review of the ACLS pulseless algorithm for PEA for ICU nurses.

1. CODE MANAGEMENT
Pulseless Electrical Activity (PEA)

2. PEA
OBJECTIVES:
• Define PEA
• Narrow Complex PEA
• Wide Complex PEA
• ACLS Cardiac Arrest Algorithm for
PEA
• ACLS Post Cardiac Arrest Care
Algorithm

3. PEA
What is PEA?
• PEA is defined as, “…spontaneous
organized cardiac electric activity in the
absence of blood flow sufficient to
maintain consciousness and absence of
a rapid spontaneous return of
adequate organ perfusion and
consciousness.” Circulation.
2013;128:2532-2541
• https://doi.org/10.1161/CIRCULATIONA
HA.113.004490

4. PEA
What can cause PEA?
• PEA is the result of underlying
pathological process.
What is the goal of care?
• Resolution of the ‘cause’ or
‘problem’ is essential for
ROSC.

5. PEA
• In ACLS the Hs & Ts are used
to describe possible causes
of a PEA arrest.
• However, the patient’s
history and EKG can help
guide interventions.
• Furthermore, for admitted
hospital patients there are
specific common causes of a
PEA arrest (Littman et al).

6. PEA
Narrow
QRS
Cardiac
Tomponade
• Pericardialcentesis
Pneumothorax
• Needle
Decompression
• Chest Tube
Massive PE
• TPA 50-100mg IV
Volume Loss
• IV Fluids
• Blood Products
• Massive Transfusion
Wide QRS
Hyperkalemia
•D50W amp + Hum “R” 5-
10 units
•NaHCO3- IV
•CaCl IV
Acidosis
• Increase ventilation
(↓CO2)
• NaHCO3- IV
MI
•Cath Lab
•TNK
Toxins
• Specific antidote
• CCB / Beta Blocker /
TCA

7. PEA
What do I need to know?
• You do not shock PEA
• CPR 30:2 (minimize interruptions)
• Epinephrine 1mg IV or IO q3-5
minutes
• Atropine 0.5-1mg IV or IO (in rare
cases)
• Fix the problem!
• If ROSC → Post Cardiac Arrest
Algorithm
• If VF / VT → VF / VT Algorithm

8. PEA

9. PEA
What happens if we achieve ROSC?
• Prepare to manage Post Cardiac
Arrest Syndrome.
• Occurs with the return of
spontaneous circulation.
• Ischemia and reperfusion injury can
cause vasodilation (low BP).
• Cardiac dysfunction and pump failure
(dilated cardiomyopathy).
• Post cardiac arrest brain injury.
• Severity depended on duration of
code and patient history.

10. PEA
How do I manage Post Cardiac
Arrest Syndrome?
• Airway management
• Sedation
• Levophed Infusion
• Antiarrhythmic Agents
• Labs / CXR / CT
• Transfer to ICU, OR, or Cath
Lab.
• Consider cooling the patient

11. PEA
References:
 ACLS 2015 PEA and Post Cardiac Arrest guidelines
 CC 90-015 – D
http://policy.nshealth.ca/Site_Published/DHA9/document_render.aspx?docum
entRender.IdType=6&documentRender.GenericField=&documentRender.Id=53
045
 Pulseless Electrical Activity, Circulations, 2013;128;2532-2541
http://circ.ahajournals.org/content/128/23/2532.short
 A Simplified and Structured Teaching Tool for the Evaluation and
Management of Pulseless Electrical Activity, Medical Principals & Practice,
2014;23:1-6 https://www.karger.com/Article/FullText/354195
 Post Cardiac Arrest Syndrome A Review of Therapeutic Strategies, Circulation,
2011;123:1428-1435. http://circ.ahajournals.org/content/123/13/1428