Pulseless electrical activity surgery

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]


External and internal pacing have not been shown to improve outcome and are not recommended. There may be capture of the signals, but there is no improvement in contractility. In appropriate patients with pulseless electrical activity (PEA), pericardiocentesis and emergent cardiac surgery may be lifesaving procedures. When adequate expertise is available, thoracotomy can be performed in refractory cases, if the patient had chest trauma. Circulatory assistance (e.g., intra-aortic balloon pump, extracorporeal membrane oxygenation, cardiopulmonary bypass, and ventricular assist device), can be used to manage patients with near pulseless electrical activity or a very low-output state.The chances of a successful outcome depend on a very coordinated resuscitation process where specific person responsible for specific steps and a good team leader should be available.


The following can be used in selected patients:[1][2][3][4][5][6]

  • Pericardiocentesis
  • Emergent cardiac surgery
  • Thoracotomy

Patients with near pulseless electrical activity or a very low-output state can be managed with:

  • Circulatory assistance
  • Intra-aortic balloon pump
  • Extracorporeal membrane oxygenation
  • Cardiopulmonary bypass
  • Ventricular assist device

Below is an algorithm summarizing the approach to a patient with pulseless electrical activity.

Pulseless electrical activity
Start CPR for 2 minutes
Give oxygen
Attach monitor and defibrillator
IV/IO access
Epinephrine Q3-5 min
Consider advanced airway, capnography
See VF/VT algorithm
CPR for 2 minutes
Treat Hs&Ts
Epinephrine Q3-5min
ROSC(return of spontaneous circulation
Post–Cardiac Arrest Care

The algorithm is based on the 2010 American Heart Association ACLS algorithm for PEA.[8]


  1. "StatPearls". 2020. PMID 30020721.
  2. Teodorescu C, Reinier K, Uy-Evanado A, Ayala J, Mariani R, Wittwer L, Gunson K, Jui J, Chugh SS (September 2012). "Survival advantage from ventricular fibrillation and pulseless electrical activity in women compared to men: the Oregon Sudden Unexpected Death Study". J Interv Card Electrophysiol. 34 (3): 219–25. doi:10.1007/s10840-012-9669-2. PMC 3627722. PMID 22406930.
  3. Littmann L, Bustin DJ, Haley MW (2014). "A simplified and structured teaching tool for the evaluation and management of pulseless electrical activity". Med Princ Pract. 23 (1): 1–6. doi:10.1159/000354195. PMC 5586830. PMID 23949188.
  4. Patil KD, Halperin HR, Becker LB (June 2015). "Cardiac arrest: resuscitation and reperfusion". Circ. Res. 116 (12): 2041–9. doi:10.1161/CIRCRESAHA.116.304495. PMC 5920653. PMID 26044255.
  5. Deyell MW, Krahn AD, Goldberger JJ (June 2015). "Sudden cardiac death risk stratification". Circ. Res. 116 (12): 1907–18. doi:10.1161/CIRCRESAHA.116.304493. PMC 4466101. PMID 26044247.
  6. Yu HH, Jeng JR (2017). "Pulseless electrical activity in acute massive pulmonary embolism during thrombolytic therapy". Ci Ji Yi Xue Za Zhi. 29 (1): 50–54. doi:10.4103/tcmj.tcmj_7_17. PMC 5509188. PMID 28757765.
  7. "The Approach to Cardiac Arrest".
  8. Field JM, Hazinski MF, Sayre MR, Chameides L, Schexnayder SM, Hemphill R; et al. (2010). "Part 1: executive summary: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care". Circulation. 122 (18 Suppl 3): S640–56. doi:10.1161/CIRCULATIONAHA.110.970889. PMID 20956217.

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