Pulseless electrical activity causes

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mahmoud Sakr, M.D. [2]


Pulseless electrical activity is defined as the absence of a pulse or cardiac contractility despite the presence of electrocardiographic activity. Pulseless electrical activity is a life-threatening condition and must be treated as such irrespective of the causes. Common causes of PEA include respiratory failure in 40% to 50% of cases, and hypovolemia. Hypovolemia, Hypoxia, Hydrogen ions (Acidosis), HypothermiaHyperkalemiaor Hypokalemia, Hypoglycemia, Tablets or Toxins (Drug overdose) such as beta blockers, tricyclic antidepressants, or calcium channel blockers, Tamponade, Tension pneumothorax, Thrombosis (Myocardial infarction), Thrombosis (Pulmonary embolism), Trauma (Hypovolemia from blood loss), Covid-19.


Life Threatening Causes

Pulseless electrical activity is a life-threatening condition and must be treated as such irrespective of the causes. Life-threatening conditions can result in death or permanent disability within 24 hours if left untreated.[1][2]

Common Causes

Common causes of PEA include the following: The common causes of PEA can be remembered using the mnemonic "The Hs and Ts".[3][4][5][2][6][7]

Causes by Organ System

Cardiovascular Acute coronary syndrome, aortic aneurysm rupture, Brugada syndrome, cardiac amyloidosis,[8] Cardiac tamponade , cardiac tumor, complete heart block, congenital heart disease, congestive heart failure, dilated cardiomyopathy, hypertensive heart disease, hypertrophic cardiomyopathy, ischemic heart disease, long QT syndrome, myocardial infarction, myocarditis, NSTEMI, pericarditis, rheumatic valvular disease,[9] STEMI, valvular heart disease
Chemical/Poisoning Alcohol
Dental No underlying causes
Dermatologic No underlying causes
Drug Side Effect Beta-blockers, calcium channel blockers, digitalis, methylphenidate,[10] propofol, quinidine, risperidone[11]
Ear Nose Throat No underlying causes
Endocrine Diabetic ketoacidosis, hypoglycemia
Environmental Hypothermia
Gastroenterologic Bowel necrosis,[12] tension pneumoperitoneum[13]
Genetic Brugada syndrome, congenital heart block, congenital heart disease
Hematologic No underlying causes
Iatrogenic Cardiac transplantation, coronary artery bypass grafting, heart surgery, hypertrophic cardiomyopathy alcohol septal ablation,[14] postdefibrillation[15]
Infectious Disease Aspiration pneumonia, myocarditis, pericarditis, septic shock
Musculoskeletal/Orthopedic No underlying causes
Neurologic Seizure
Nutritional/Metabolic Hypermagnesemia, metabolic acidosis
Obstetric/Gynecologic No underlying causes
Oncologic Cardiac tumor
Ophthalmologic No underlying causes
Overdose/Toxicity Alcohol,[16] propofol, quinidine
Psychiatric Takotsubo cardiomyopathy
Pulmonary Aspiration pneumonia, bronchospasm, hypoxia, tension pneumothorax
Renal/Electrolyte Hyperkalemia, Hypovolemia, renal failure
Rheumatology/Immunology/Allergy Cardiac amyloidosis,[8] rheumatic valvular disease, severe anaphylaxis to syntocinon[17]
Sexual No underlying causes
Trauma Myocardial contusion, severe brain injury
Urologic No underlying causes
Miscellaneous No underlying causes

Causes in Alphabetical Order


  1. Shao F, Xu S, Ma X, Xu Z, Lyu J, Ng M, Cui H, Yu C, Zhang Q, Sun P, Tang Z (April 2020). "In-hospital cardiac arrest outcomes among patients with COVID-19 pneumonia in Wuhan, China". Resuscitation. doi:10.1016/j.resuscitation.2020.04.005. PMC 7151543 Check |pmc= value (help). PMID 32283117 Check |pmid= value (help).
  2. 2.0 2.1 Stueven H, Troiano P, Thompson B, Mateer JR, Kastenson EH, Tonsfeldt D; et al. (1986). "Bystander/first responder CPR: ten years experience in a paramedic system". Ann Emerg Med. 15 (6): 707–10. PMID 3706861.
  3. ACLS: Principles and Practice. p. 71-87. Dallas: American Heart Association, 2003. ISBN 0-87493-341-2.
  4. ACLS for Experienced Providers. p. 3-5. Dallas: American Heart Association, 2003. ISBN 0-87493-424-9.
  5. "2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care - Part 7.2: Management of Cardiac Arrest." Circulation 2005; 112: IV-58 - IV-66.
  6. Sandberg WS (2005). "Endobronchial blocker dislodgement leading to pulseless electrical activity". Anesth Analg. 100 (6): 1728–30. doi:10.1213/01.ANE.0000149895.99151.20. PMID 15920204.
  7. Li H, Liu SM, Yu XH, Tang SL, Tang CK (March 2020). "Coronavirus disease 2019 (COVID-19): current status and future perspectives". Int. J. Antimicrob. Agents: 105951. doi:10.1016/j.ijantimicag.2020.105951. PMC 7139247 Check |pmc= value (help). PMID 32234466 Check |pmid= value (help).
  8. 8.0 8.1 8.2 Hess EP, White RD (2004). "Out-of-hospital cardiac arrest in patients with cardiac amyloidosis: presenting rhythms, management and outcomes in four patients". Resuscitation. 60 (1): 105–11. doi:10.1016/j.resuscitation.2003.08.007. PMID 14987790.
  9. Virkkunen I, Paasio L, Ryynänen S, Vuori A, Sajantila A, Yli-Hankala A; et al. (2008). "Pulseless electrical activity and unsuccessful out-of-hospital resuscitation: what is the cause of death?". Resuscitation. 77 (2): 207–10. doi:10.1016/j.resuscitation.2007.12.006. PMID 18249482.
  10. 10.0 10.1 Daly MW, Custer G, McLeay PD (2008). "Cardiac arrest with pulseless electrical activity associated with methylphenidate in an adolescent with a normal baseline echocardiogram". Pharmacotherapy. 28 (11): 1408–12. doi:10.1592/phco.28.11.1408. PMID 18957001.
  11. 11.0 11.1 Ravin DS, Levenson JW (1997). "Fatal cardiac event following initiation of risperidone therapy". Ann Pharmacother. 31 (7–8): 867–70. PMID 9220048.
  12. 12.0 12.1 Fang AC, Carnell J, Stein JC (2012). "Constipation in a 7-year-old boy: congenital band causing a strangulated small bowel and pulseless electrical activity". J Emerg Med. 42 (3): 283–7. doi:10.1016/j.jemermed.2010.05.092. PMID 20832966.
  13. 13.0 13.1 Peppriell JE, Bacon DR (2000). "Acute abdominal compartment syndrome with pulseless electrical activity during colonoscopy with conscious sedation". J Clin Anesth. 12 (3): 216–9. PMID 10869921.
  14. 14.0 14.1 ten Cate FJ, Soliman OI, Michels M, Theuns DA, de Jong PL, Geleijnse ML, Serruys PW (2010). "Long-term outcome of alcohol septal ablation in patients with obstructive hypertrophic cardiomyopathy: a word of caution". Circulation. Heart Failure. 3 (3): 362–9. doi:10.1161/CIRCHEARTFAILURE.109.862359. PMID 20332420. Retrieved 2012-02-11. Unknown parameter |month= ignored (help)
  15. 15.0 15.1 Geddes LA, Roeder RA, Rundell AE, Otlewski MP, Kemeny AE, Lottes AE (2006). "The natural biochemical changes during ventricular fibrillation with cardiopulmonary resuscitation and the onset of postdefibrillation pulseless electrical activity". Am J Emerg Med. 24 (5): 577–81. doi:10.1016/j.ajem.2006.01.030. PMID 16938597.
  16. Stueven HA, Aufderheide T, Waite EM, Mateer JR (1989). "Electromechanical dissociation: six years prehospital experience". Resuscitation. 17 (2): 173–82. PMID 2546233.
  17. 17.0 17.1 Pant D, Vohra VK, Pandey SS, Sood J (2009). "Pulseless electrical activity during caesarean delivery under spinal anaesthesia: a case report of severe anaphylactic reaction to Syntocinon". Int J Obstet Anesth. 18 (1): 85–8. doi:10.1016/j.ijoa.2008.09.004. PMID 19111230.

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