Pulseless Electrical Activity Guidelines

Updated: Mar 27, 2018
  • Author: Sandy N Shah, DO, MBA, FACC, FACP, FACOI; Chief Editor: Jose M Dizon, MD  more...
  • Print

Guidelines Summary

Advanced cardiac life support guidelines

Updated cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) guidelines were issued in 2015 by the following organizations:

  • American Heart Association (AHA) [3]
  • European Resuscitation Council (ERC) [4]
  • The International Liaison Committee on Resuscitation (ILCOR) [29]

Overall, the three guidelines concur that the recommendations for a patient in whom pulseless electrical activity (PEA) is suspected are the following [3, 4, 29] :

  • Activate the emergency response system.
  • Initiate CPR, and give oxygen when available.
  • Place an intravenous (IV) line.
  • Intubate the patient.

Once these basic measures are in place, reversible causes should be sought and corrected. These include the following:

  • Hypovolemia
  • Hypoxia
  • Acidosis
  • Hypokalemia/hyperkalemia
  • Hypoglycemia
  • Hypothermia
  • Toxins (eg, tricyclic antidepressants, digoxin, calcium channel blocker, beta-blockers)
  • Cardiac tamponade
  • Tension pneumothorax
  • Massive pulmonary embolus
  • Acute myocardial infarction

Adjuncts for airway control and ventilation

The AHA guidelines also provide the following recommendations for airway control and ventilation [3, 30] :

  • Advanced airway placement in cardiac arrest should not delay initial CPR and defibrillation for ventricular fibrillation arrest. (Class I)
  • If advanced airway placement will interrupt chest compressions, consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates return of spontaneous circulation (ROSC). (Class IIb)
  • The routine use of cricoid pressure in cardiac arrest is not recommended. (Class III)
  • Either a bag-mask device or an advanced airway may be used for oxygenation and ventilation during CPR in both the in-hospital and out-of-hospital setting. (Class IIb) The choice of bag-mask device versus advanced airway insertion should be determined by the skill and experience of the provider.
  • For healthcare providers trained in their use, either an supraglottic airway (SGA) device or an endotracheal tube (ETT) may be used as the initial advanced airway during CPR. (Class IIb)
  • Providers who perform endotracheal intubation should undergo frequent retraining (Class I)
  • To facilitate delivery of ventilations with a bag-mask device, oropharyngeal airways can be used in unconscious (unresponsive) patients with no cough or gag reflex and should be inserted only by trained personnel. (Class IIa)
  • In the presence of known or suspected basal skull fracture or severe coagulopathy, an oral airway is preferred. (Class IIa)
  • Continuous waveform capnography in addition to clinical assessment is the most reliable method of confirming and monitoring correct placement of an ETT. (Class I)
  • If continuous waveform capnometry is not available, a nonwaveform CO 2 detector, esophageal detector device, or ultrasound used by an experienced operator is a reasonable alternative. (Class IIa)
  • After placement of an advanced airway, it is reasonable for the provider to deliver 1 breath every 6 seconds (10 breaths/min) while continuous chest compressions are performed. (Class IIb)
  • Automatic transport ventilators (ATVs) can be useful for ventilation of adult patients in noncardiac arrest who have an advanced airway in place in both out-of-hospital and in-hospital settings. (Class IIb)

There are no significant differences in the recommendations from the ERC or ILCOR. [4, 29]

Medication management

The 2015 AHA guidelines offers the following recommendations for the administration of drugs [3, 30] :

  • Atropine during PEA or asystole is unlikely to have a therapeutic benefit. (Class IIb)
  • There is insufficient evidence for or against the routine initiation or continuation of other antiarrhythmic medications after ROSC from cardiac arrest.
  • Standard-dose epinephrine (1 mg every 3-5 minutes) may be reasonable for patients in cardiac arrest. (Class IIb); high-dose epinephrine is not recommended for routine use in cardiac arrest. (Class III)
  • It may be reasonable to administer epinephrine as soon as feasible after the onset of cardiac arrest due to an initial nonshockable rhythm. (Class IIb)
  • Vasopressin has been removed from the adult cardiac arrest algorithm as it offers no advantage in combination with epinephrine nor as a substitute for standard-dose epinephrine. (Class IIb for both)