PULSELESS

ELECTRI
CAL
ACTIVITY
KAREN P. IDANG RN
Learning Objectives:

 Be able to apply ACLS approach

(primary and secondary ABCD survey)
 Be able to establish the critical system:
airway, breathing, circulation,
defibrillation
 Be able to state 10 causes of PEA arrest
 Case Scenario:
A 55 yr. old man walks into the ER
complaining of severe chest pain and
abdominal pain. He is placed on a
stretcher and begins to remove his
clothes. Just as the ER-nurse starts to
attach the monitor leads, he falls back
unconscious on the stretcher.
 ECG: PEA? Sinus Rhythm?
 ECG: PEA?
sinus tachycardia with no pulse?
 ECG: PEA? Asystole?
 ECG: PEA? Idioventricular Rhythm?
EMD?
 ECG: PEA? Junctional Rhythm?
Pulseless Electrical
Activity
PRIMARY ABCD survey
A: Airway = open the airway

B: Breathing = provide positive pressure

ventilation

C: Circulation = give chest compressions

D: Defibrillation = not indicated

Pulseless Electrical
Activity
SECONDARY ABCD survey
A: Airway = place device ASAP
B: Breathing = confirm airway device by PE, tube
confirmation, secure airway device to prevent
dislodgement, confirm effective oxygenation and
ventilation
C: Circulation = identify rhythm, establish IV
access, administer drugs appropriate for rhythm
condition, assess for occult blood flow (“pseudo-
EMD”)
D: Differential = search for and treat identified
causes
Pulseless Arrest

 BLS algorithm: call fro help, give CPR

 Give oxygen when available
 Attach monitor/defibrillator when
available
 Pulseless Arrest
 Check Rhythm: Shockable Rhythm?
ASYSTOLE/PEA (not shockable)
> CPR immediately for 5 cycles
> When IV/IO available, give vasopressor
Epinephrine 1mg
Repeat every 3 to 5 mins OR
may give 1 dose of Vasopressin 40 U
IV/IO to replace 1st or 2nd dose of epinephrine
> Consider Atropine 1mg IV/IO for
asystole or slow PEA rate, repeat
every 3 to 5 min (up to 3 doses)
Pulseless Arrest: During
CPR
 Push hard and fast (100/min)
 Ensure full chest recoil
 Minimize interruptions in chest compression
 One cycle of CPR: 30 compressions then 2
breaths, 5 cycles = 2 minutes
 Avoid hyperventilation
 Secure airway and confirm placement
Pulseless Arrest: During
CPR
= After an advanced airway is placed,
rescuers no longer deliver “cycles” of
CPR. Give continuous chest
compressions without pauses fro
breaths. Give 8 to 10 breaths/min. Check
rhythm every 2 minutes
 Rotate compressors every 2 minutes
with rhythm checks
Pulseless Arrest: During
CPR
 Search for Reversible causes: 5H’s & 5T’s
5H’s = Hypovolemia, Hypoxia, Hydrogen ions
(ACIDOSIS), Hyper – Hypo kalemia,
Hypothermia, Hypoglycemia

5T’s = Tablets/Toxins, Tamponade (cardiac),

Tension Pneumothorax, Thrombosis (ACS
or Pulm. Embolism), Trauma
Cardiac Tamponade

 Pathophysiology:
> Impairment of ventricular diastolic filling
caused by pressure of pericardial sac
and bulging of ventricular septum into the
LV. Stroke volume and cardiac output
falls
Cardiac Tamponade
Cardiac Tamponade
 Clinical Signs:
> pulsus paradoxus
> pericardial friction rub may be present
> heart size on Xray may be normal or
enlarged
> Echocardiogram
> ECG: electrical alternans
 Cardiac Tamponade
CXR: widened
mediastinum
Cardiac Tamponade

CT Scan:
Cardiac Tamponade
ECG: electrical alternans
2D ECHO:
2D ECHO: M-mode
Cardiac Tamponade

 Clinical Manifestations:
> CVP elevated
> early rapid ventricular filling inhibited
> intracardiac pressures equalize
during diastole
> pulsus paradoxus usually present
Cardiac Tamponade

 Pressures in Cardiac Tamponade:

Cardiac Tamponade

 Pericardiocentesis:
> therapeutic and diagnostic
procedure in which fluid is removed
from the pericardium, the sac that
surrounds the heart.
Pericardiocentesis
 General Principles: (update)
> As of 2000: ECG used to guide
pericardiocentesis

> Direct subxyphiod techniques only used

in medical emergency

> ECG and hemodynamic monitoring

> Full resuscitation equipment available

Pericardiocentesis

 Indications:
> immediate threat to life
> severe hemodynamic impairment
> fall in systolic blood pressure
Pericardiocentesis

 Technique:
> patient in supine position upper
torso elevated
> ECG: limb leads attached to patient
> use Echo guided procedure
> Subxyphoid approach
> Continuous aspiration
Pericardiocentesis

 Equipment:
> 16g needle, short bevel, large bore
> 30 or 50cc syringe
> Echo or ECG guided
> local anesthetic
> sterile supplies
Pericardiocentesis
Pericardiocentesis
Pericardiocentesis

 ECG guided needle advancement:

Pericardiocentesis Echo
Guided
Pericardiocentesis

 Complications:
> Cardiac arrhythmia
> laceration of myocardium or
coronary arteries
> injection of air into cardiac
chambers
> hydrothorax or pnuemothorax
> Hemorrhage from laceration
Pneumothorax

 Definition:
> entry of air into pleural space
causing lung collapse
 Tension Pneumothorax
 Definition:
> air under pressure
> venous return inhibited
> mediastinum displaced
> vena cava kinked
> cardiac output decreased
> cardiovascular collapse developed
Tension Pneumothorax
 Clinical manifestation:
> spontaneous breathing
> respiratory distress
> florid face
> tracheal deviation
> distended neck veins
> tachycardia
> hypotension
 Tension Pneumothorax
CXR: pleural
margin with partial
lung collapse

collapsed lung
Tension Pneumothorax
CT Scan:
Tension Pneumothorax
Tension Pneumothorax

 Treatment:
> provide treatment as soon as
diagnosis is apparent to prevent
cardiovascular collapse and cardiac
arrest
> do not wait fro XRAY confirmation
> use large bore needle tap
Tension Pneumothorax
 Equipment:
> 14g large bore needle
> sterile materials
 Technique:
> cleanse overlying skin
> insert needle at 2nd or 3rd ICS-MCL,
over top of rib
> leave catheter in pleural space open to
air then place on water sealed
bottle
Tension Pneumothorax
Tension Pneumothorax
 Complications:
> misdiagnosis – pneumothorax created
> lung laceration
> internal mammary or intercostal
vessel laceration
> pneumothorax
Critical Actions - PEA

 Perform all steps in ABCD survey and

CPR
 Operate monitor
 Recognize PEA
 Direct intubation and assess ventilation
 Direct IV access
Critical Actions - PEA

 Assess patient and name conditions

causing PEA
 Determine management
 Administer fluid challenge
 Administer epinephrine
 Administer Atropine if rate is low
Common Perils and
Pitfalls
 Not assessing patient
 Not considering possible causes
 Only treating with epinephrine
 Not trouble shooting ventilation/intubating
patient
 Not giving volume infusion
 Defibrillation
 Not performing chest compressions
Rhythms to Learn

 Electromechnical dissociation
 Idioventricular rhythm
 Pulseless asystole
 Bradyasystole rhythm
 Ventricular junctional escape
 Pseudo EMD
Thank you!