Pulseless Electrical Activity (PEA)

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Section 4 - CARDIAC


Pulseless Electrical Activity is a condition associated with poor outcomes. It is identified by the presence of cardiac electrical activity with no corresponding mechanical pulse or signs of perfusion. It is important to CONFIRM true PEA early in the management of the case. Consider all possible reversible causes for PEA utilizing a national recommended mnemonic of “H’s and T’s”:

H’s T’s
Hypovolemia Tension Pneumothorax
Hypoxia Tamponade, cardiac
Hydrogen Ion (acidosis) Toxins or Tablets (overdose)
Hypo/hyperkalemia Thrombosis, pulmonary
Hypothermia Thrombosis, cardiac

In addition, also consider the following:

Hypoglycemia Trauma


When the Patient found in True PEA:

  • Initiate 5 cycles of high quality CPR (push hard/push fast)
    • Minimum of 100 compressions per minute, minimize interruptions
    • Compression rate of 30:2 for approximately 2 minutes
    • Depth of compression of at least 2 inches
    • Initiate the use of a mechanical compression device if available
  • Assist ventilations with OXYGEN @ 100% via BVM - DO NOT HYPERVENTILATE
  • Establish intravenous access via IV or IO
  • Reassess for circulation every two minutes
  • Consider advanced airway procedure using supraglottic airway (king tube) or endotracheal intubation
    • Do not interrupt compressions to place an advanced airway
    • Confirm tube placement with capnography (a range 5-20 mmHg is indicative of low cardiac output)
  • If hypovolemia suspected, administer IV fluid bolus 200 - 300 ml and reassess

Pharmacologic Therapy:

The current national guidelines do not include ATROPINE from treatment of TRUE PEA as there is no proof it has a therapeutic benefit.

Under the Seminole County Practice Parameters the use of ATROPINE SULFATE is indicated in cardiac arrest that may be caused by extreme bradycardia/hypotension.

Check for pulse and rhythm change after all interventions.

Cases of suspected bradycardia, relative bradycardia or vagally stimulated such as patients found in the restroom.

  • First, ATROPINE 0.5 -1.0 mg rapid IVP. Repeat every 3 - 5 minutes up to a total of 0.04 mg/kg or approximately 3 mg
  • Apply TCP, set at maximum Milliamp. If pulse generated, decrease dosage to setting which still maintains a palpable pulse. If unsuccessful, reattempt capture every 3 - 5 minutes as above
  • EPINEPHRINE 1:10,000 1 mg IVP or IO Repeat EPINEPHRINE every 3 - 5 minutes of continued arrest

If patient combative post resuscitation, refer to ANALGESIA /SEDATION PARAMETER (2.04).

Termination of Resuscitation:

In Medical Related Cardiac Arrests, the paramedic may terminate resuscitative efforts in Non-Hypothermic Adults provided all of the following criteria have been provided and established:

  • Patient initially presents and maintains PEA
  • Airway has been successfully controlled (not necessarily intubated)
  • If clinically indicated - ATROPINE SULFATE 1.0 mg rapid IVP/ IO has been administered and allowed time to circulate x1.
  • EPINEPHRINE 1:10,000 1 mg IVP or IO has been administered & allowed time to circulate x1, or
  • VASOPRESSIN 40 units IVP has been administered and allowed time to circulate. x1
  • EtCO2 is (less than) < 20 mm Hg
  • Efforts to verify akinetic heart have been taken
    • Lack of Heart sounds
    • Rule out of H's and T's


  • After 15 minutes of ALS procedures without any response or return of spontaneous circulation


  • After the patient’s personal medical doctor agrees to sign the death certificate

Contact will be made in conjunction and compliance with Federal, State, Local, and Agency Laws and Policies regarding patient body care and removal.

A paramedic may decide to continue resuscitation efforts as outlined in these Practice Parameters. Reasons to continue may include scene safety, location, and input from present family members.