![]() ![]() Wide-complex PEA usually suggests a metabolic problem such as severe hyperkalemia with or without metabolic acidosis, or sodium channel blocker toxicity (fig. Thoracic ultrasonography may also help in direct pleural assessment and in the diagnosis of pneumothorax. A dilated right ventricle, on the other hand, indicates possible pulmonary embolism. A collapsed right ventricle suggests inflow obstruction from tamponade, pneumothorax or hyperinflation. In all of these cases cardiac ultrasound usually shows preserved or even hyperdynamic left ventricular function indicative of pseudo-PEA (fig. Cancer history and deep venous thrombosis suggest pulmonary embolism. Rib fracture, severe emphysema, positive pressure ventilation and hyperexpanded chest indicate pneumothorax, mechanical hyperinflation or auto-PEEP. Jugular venous distension and muffled heart sounds suggest tamponade. The clinical scenario can usually help navigate between these causes. The four most common mechanical causes of PEA arrest include cardiac tamponade, tension pneumothorax, mechanical hyperinflation and pulmonary embolism (fig. LV = Left ventricular PTX = pneumothorax US = ultrasound RV = right ventricular. New classification of PEA based on its initial electrocardiographic manifestation. This algorithm has not been systematically tested but is supported by scientific and clinical principles and by a thorough review of the literature. Our algorithm does not apply in the specific trauma setting. Over the last few years we have developed a teaching tool that simplifies the diagnostic approach by differentiating narrow- and wide-complex rhythms on initial telemetry (QRS duration <0.12 and ≥0.12 s, respectively), and by eliminating those diagnoses which rarely if ever cause PEA. ![]() There were also attempts to use the electrocardiogram (ECG) and bedside echocardiogram to guide the diagnosis and management of PEA. These limitations of current ACLS guidelines have been recognized and attempts have been made to simplify the evaluation of patients who present with cardiac arrest due to PEA. Hypoglycemia and trauma have been removed from the most recent ACLS guidelines. Moreover, even if such a list can be generated, the ACLS does not provide guidance on the relative likelihood of the specific causes, nor does it offer suggestions on how to individualize treatments based on simple initial findings.Ĭauses of PEA listed by European and American guidelines. Studies, however, have shown that during cardiopulmonary resuscitation it is difficult to recall up to 13 causes of PEA. Memory aids list numerous conditions whose English names start with the letters H or T as potentially treatable causes of PEA (fig. Both the European and American ACLS guidelines, therefore, stress the significance of quickly finding and addressing the cause of PEA. ![]() Higher-dose epinephrine has actually been shown to be associated with worse outcomes. Studies suggest that cause-specific treatment of PEA is more effective than general treatments offered by advanced cardiac life support (ACLS) guidelines such as cardiac massage, epinephrine and vasopressin. The survival rate of patients with PEA is much worse than that of cardiac arrest patients with shockable rhythms. Patients with pulseless electrical activity (PEA) account for up to 30% of cardiac arrest victims.
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