Updated: 12/21/2019

Pulseless Electrical Activity and Asystole

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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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