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Chapter 11 : Pulseless Electrical Activity

Pulseless electrical activity (PEA) is lack of palpable pulse or cardiac contraction even with an organized cardiac electrical activity. Even though the heart is producing organized electrical activity, no mechanical activity is produced. There will be no contractions of the cardiac muscles. Any organized rhyme without a pulse is PEA (except VF, VT and asystole) and includes: idioventricular rhythms, ventricular escape rhythms, post-defibrillation idioventricular rhythms, and Bradyasystolic rhythms.


PEA can be caused by many factors and are represented as H’s and T’s:

H’s T’s
Hypovolemia – Decreased blood volume Tension pneumothorax – air in the pleural space around the lung (lung collapses)
Hypoxia- decreased partial pressure of oxygen in blood Tamponade – compression of the heart produced by excess fluid surrounding the heart
Hydrogen ion (acidosis) – Increase in the concentration of H ions in blood Toxins – poisonous substances
Hyper-/hypokalemia –abnormally high or low potassium concentration in the blood Thromobosis (pulmonary) – formation of a blood clot which blocks a blood vessel in lungs
Hypothermia – core temp is less than 96.8 F, and severe is less than 86 F Thrombosis (coronary) –formation of a blood clot which blocks a blood vessel in heart

Scenario: You are the physician on duty and are called to the ER to see a patient who was involved in a motorcycle accident and is now unresponsive.


  1. Check for responsiveness – Tap and shout “Are you alright?” and look at chest for movement.  Check carotid pulse and note no pulse is present
  2. Call a code and get the code team in place


  1. If no pulse, immediately start compressions at a rate of 100 compressions per minute and allow chest to recoil. 30 compressions to 2 breaths. Once team is in place, one person will be responsible for the compressions and one for breaths using a BVM.
  2. Attach monitor and check for shockable rhythm, if no shockable rhythm present, the patient is in asystole or PEA, continue CPR for 2 mins and obtain IV/IO access Management: Initiate the cardiac arrest algorithm on the right if the patient still has no pulse and does not respond to BLS

    1. Once IV/IO access is obtained give the following drugs:
      • Epinephrine 1 mg IV/IO and repeat every 3 to 5 minutes
    2. Maintain advanced airway and capnography if needed
    3. Pause and check for shockable rhythm. If not shockable , continue CPR for 2 minutes and try to treat the reversible causes

The following is an algorithm shows management of cardiac arrest due to asystole/PEA (left side of chart)


To ensure the best outcome for PEA it is vital to have uninterrupted, high quality CPR and to quickly figure out the reversible causes.

Learning Outcomes:
You have completed Chapter VII. Now you should be able to:

  1. Apply the Cardiac Arrest Algorithm to PEA
  2. Recognize PEA in a patient
  3. Understand the H’s & T’s in relation to PEA/Asystole
  4. Understand the treatments used in PEA

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