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Updated: Dec 7 2021

Pulseless Electrical Activity and Asystole

  • Snapshot
    • A 42-year-old man falls to the ground abruptly. Prior to the fall, he felt lightheaded and experienced palpitations. Chest compressions are immediately performed and he was placed on a Lucas device en route to the emergency department. In the emergency department, a defibrillator is placed on the patient, which does not show a shockable rhythm. The electrocardiogram demonstrates electrocardiographic activity but he does not have a pulse. The patient is given epinephrine in addition to chest compressions. After 1 hour of management, he returns to spontaneous circulation. (Pulseless electrical activity)
  • Introduction
    • Definition
      • pulseless electrical activity (PEA)
        • the presence of electrocardiographic rhythm without a palpable pulse or measurable blood pressure
          • the heart is unable to generate enough mechanical contraction
          • this is a non-perfusing rhythm, thus requiring effective cardiopulmonary resuscitation
      • asystole
        • an absence of electrocardiographic and mechanical cardiac activity
  • Etiology
    • The H's and T's
      • Hypothermia
      • H+ (acidosis)
      • Hypo- or hyperkalemia
      • Hypoxia
      • Hypovolemia
      • Thrombosis
      • Tamponade
      • Tension pneumothorax
      • Toxins
  • Presentation
    • Symptoms
      • cardiac arrest
    • Physical exam
      • absent pulses
  • Studies
    • Electrocardiogram
      • required to make the diagnosis
  • Treatment
    • Initiate advanced cardiovascular life support (ACLS)
      • begin with CAB
        • Circulation
        • Airway
        • Breathing
      • perform chest compressions, give oxygen, and connect the patient to a defibrillator
        • next determine if the patient has a shockable rhythm
          • note that PEA and asystole are not shockable rhythms
        • PEA and asystole
          • give epinephrine every 3-5 minutes along with chest compressions until the patient has a shockable rhythm or a return of spontaneous circulation
    • Manage the underlying cause (H's and T's)
      • Hypothermia
        • warming
      • H+ (acidosis)
        • reverse the acidosis
      • Hypo- or hyperkalemia
        • hypokalemia
          • provide potassium
        • hyperkalemia
          • e.g., calcium gluconate and insulin-dextrose
      • Hypoxia
        • oxygen and secure the airway
      • Hypovolemia
        • fluid replacement
      • Thrombosis (e.g., myocardial infarction and pulmonary embolism)
        • thrombolytics
      • Tamponade
        • pericardiocentesis
      • Tension pneumothorax
        • needle decompression
      • Toxins
        • antidotes (e.g., hydroxocobalamin in cyanide toxicity)
  • Complications
    • If systemic perfusion is not restored, will inevitably lead to death
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