Pulseless electrical activity medical therapy
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The current American Heart Association-Advanced Cardiac Life Support (AHA-ACLS) guidelines advise the following be undertaken in all patients start CPR immediately, administer 100% oxygen to reverse hypoxia,Intubate the patient, establish IV access.The mainstay of drug therapy for PEA is epinephrine 1mg every 3–5 minutes. Higher doses of epinephrine can be administered in patients with suspected beta blocker and calcium channel blocker overdose. Immediately after administering epinephrine attention should be directed to reverse any possible causes of PEA as they are the most common causes like hypovolemia (i.e. hypovolemic shock) which should be treated with IV fluids hor packed red blood cell transfusion. Others like electrolyte abnormalities including hyper/hypokalemia should be corrected immediately as they can be life threatening as well as tension pneumothorax.
Below is an algorithm summarizing the approach to a patient with pulseless electrical activity. 
|Pulseless electrical activity|
|Start CPR for 2 minutes|
Attach monitor and defibrillator
Epinephrine Q3-5 min
Consider advanced airway, capnography
|See VF/VT algorithm||CPR for 2 minutes|
|ROSC(return of spontaneous circulation|
|Post–Cardiac Arrest Care|
Initial Treatment in All Patients
The current American Heart Association-Advanced Cardiac Life Support (AHA-ACLS) guidelines advise the following be undertaken in all patients:The algorithm is based on the 2010 American Heart Association ACLS algorithm for PEA.
- Start CPR immediately
- Administer 100% oxygen to reverse hypoxia
- Intubate the patient
- Establish IV access
Reverse The Underlying Cause
The mainstay of treatment is to reverse the underlying cause of PEA.
- Hypovolemic Shock
- The most common reversible cause is hypovolemia (i.e. hypovolemic shock) which should be treated with IV fluids or packed red blood cell transfusion.
- Tension Pneumothorax
Another readily identifiable and immediately treatable causes include tension pneumothorax (not uncommon in the ICU setting). Often in the ICU, this may occur in a ventilated patient, but conscious patients may complain of the sudden onset of chest pain, there may be the sudden appearance of cyanosis, tracheal deviation, and absent breath sounds on the involved side of the chest. In patients on a ventilator, auto ̶ positive end-expiratory pressure (auto PEEP) and rupture of a bleb are more likely to occur. A thin needle can be inserted in the upper intercostal space to relieve the pressure and allow the lung to reinflate.
- Cardiac Tamponade
- Suspect cardiac tamponade in the patient with recent chest trauma,neoplasm, or renal failure. These patients will complain of preceding sudden onset of chest pain, palpitations, breathlessness and lightheadedness. Elevated neck veins and a quiet muffled heart are present. There may be electrical alternans of the QRS complex and other intervals on the EKG.
- Cardiac Rupture
If the patient develops PEA several days after presenting with a ST elevation MI, then cardiac rupture should be considered particularly in an elderly female with hypertension.
- Recurrent Myocardial Infarction
- 8If the patient develops PEA several days after presenting with a ST elevation MI, then recurrent MI should be considered and treated accordingly
- Pulmonary Embolism
Treatment in the Absence of an Identifiable Underlying Cause
The mainstay of drug therapy for PEA is epinephrine 1mg every 3–5 minutes. Higher doses of epinephrine can be administered in patients with suspected beta blocker and calcium channel blocker overdose. Otherwise high dose epinephrine has not demonstrated a benefit in survival or neurologic recovery.
- Sodium bicorbonate
Sodium bicarbonate at a dose of 1 meq per kilogram may be considered in this rhythm as well, although there is little evidence to support this practice. Its routine use is not recommended for patients in this context, except in special situations (e.g. preexisting metabolic acidosis, hyperkalemia, tricyclic antidepressant overdose).
- PPE(personal protective equipment) should be worn always depending upon the availability before beginning CPR
- Try to minimize the head count of persons performing CPR as much as possible and also use a negative-pressure room if it is available
- Using a mechanical device to perform CPR if available, high-efficiency particulate air (HEPA) filter for bag-mask ventilation (BMV) and mechanical ventilation
- Accessing the need for early intubation
- Always avoid prolonged resuscitation efforts given the high mortality rate of adult COVID-19 patients presenting with cardiac arrest
Defibrillation is not used to treat this rhythm, as the problem lies in the response of the myocardial tissue to electrical impulses.
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