Pulseless Electrical Activity Teaching

In this lesson, we're going to let you play the role of team leader during another cardiac emergency – pulseless electrical activity (PEA). From start to finish, you'll be in charge of assessing the patient and providing therapy and treatment recommendations.

In this scenario, you've been presented with a 42-year-old male patient who fell out of a tree stand while hunting. He fell about 12 feet and may have landed on a tree stump. He walked back to his house and shortly after began to develop breathing difficulty and chest discomfort.

While interviewing the patient, he tells you that his breathing is getting more labored and he's feeling lightheaded.

Your initial assessment recap:

• 42-year-old male
• Fell about 12 feet
• Difficulty breathing
• Chest discomfort

You place the patient on O2 via nasal cannula at 4 liters and his vital signs are taken:

• Blood pressure: 98/68
• Pulse: 112 and tachy
• Respirations: 20 and shallow

The patient begins to become less coherent and stops responding to your questions.

Let's assume the scene is safe and your personal protective equipment is in place. You begin by instructing a team member to perform a tap and shout sequence to confirm the patient's unresponsiveness. And he remains unconscious and unresponsive.

Your team checks for a carotid pulse and signs of normal breathing as you all begin gathering the appropriate equipment. Your team finds no pulse and no signs of breathing.

Someone in the team either places a CPR board under the patient or if he's on a hospital bed with a CPR button, you activate it at this time. Doing so will deflate the bed and create a hard surface, which will aid CPR efforts.

CPR has been initiated – 30 compressions at a depth of 2 to 2.4 inches deep at a rate between 100 and 120 compressions per minute and followed by 2 rescue breaths.

Now is the time when you'll take a leadership role and assign team member roles. You begin by directing the recorder to record all times, treatments, and any other associated and relevant notes for that protocol.

You assign an airway person and directions to begin with a basic airway providing breaths using a bag valve mask at 15 liters of oxygen at cycles of 30 compressions to 2 rescue breaths.

While compressions are being given, you direct the monitor/defibrillator team member to attach the defibrillator pads to get the patient's initial rhythm and shock him if needed. As soon as the pads are on, you give directions to your team to pause CPR to check the patient's underlying rhythm.

You tell everyone, Stand clear while the rhythm is analyzed. It shows what looks like a slow normal sinus rhythm. You call for the airway manager to check again for a pulse, or the compressor if the airway manager is busy.

No pulse can be found, and you determine that the patient is in PEA. You direct the team to continue performing high-quality CPR and call for an IV to be established with an 18-gauge needle, start him on normal saline, and prepare to give medications.

The recorder team member states, It's been 2 minutes.

You instruct the compressor and monitor/defibrillator to switch positions to have a fresh compressor at all times. This switch should occur at least every 2 minutes or sooner if you recognize insufficient compressions due to fatigue.

You take a quick look at the monitor – no longer than 10 seconds – to see if a shock needs to be given or CPR resumed. In this scenario, you still see what looks like a slow normal sinus rhythm and ask again for a pulse check. There is still no pulse; the patient is still in PEA.

You direct the compressor to continue performing CPR and call for the first medication delivery. You call out the drug order for 1mg of 1:10,000 concentration of epi via IV push flushed with 20cc of normal saline and wait for the IV/medication team member to repeat the order back to you, which they do. You verify the repeated order by saying, That's correct.

At this time, you decide to secure an advanced airway to maintain the airway, give synchronous compressions with rescue breaths, and have the ability to monitor capnography.

As the team leader, you request an advanced airway using an endotracheal tube. Someone on the team measures for it and inserts a #7 endotracheal tube with a stylet. The ET tube balloon is inflated after it passes between the left and right lobes. You also check the patient's stomach for any air sounds.

Remember, if you cannot detect any stomach air sounds and there are good breath sounds bilaterally, you know that the ET tube is in the correct spot. The chest is also showing signs of good chest rise and fall, which also indicates the tube placement was accurate.

When the ET tube is in place and capnography is attached, you look to see if compressions and rescue breaths are effective, and CPR quality looks great.

The recorder calls out, We're at 4 minutes.

The compressor and monitor/defibrillator team member switch again after the second dose of epi is given and flushed with 20cc of normal saline.

You decide that now is a good time to ask the team for feedback to help determine why the patient is in PEA. You do this by considering the reversible H's and T's:

Since you're not sure if the trauma/fall is to blame for the PEA, or if something else is, you're open to suggestions from the team. The team considers the effects of the head and/or chest trauma from the fall and someone suggests tension pneumothorax could be the cause.

You think about this but eventually dismiss it – the patient has good equal lung sounds and has great compliance when giving ventilations, which indicates it's probably not tension pneumothorax.

Another member of the team suggests that chest trauma may be causing the PEA due to cardiac tamponade:

• Blunt trauma to the chest
• Low blood pressure
• Fast heart rate
• Fast breathing

This sounds like a good suggestion and all measures for correcting it are expedited.

However, what if all reversible causes have been eliminated and the patient remains in cardiac arrest? As team leader, you may reach a point when a decision to stop resuscitation may have to be made, especially if EtCO2 is less than 10 after 20 minutes of high-quality CPR and all treatment options have been exhausted.

In many cases, PEA will deteriorate into asystole over time. It's never easy to call it quits. Everyone has invested a lot of effort and time and everyone on the team wants to see the patient survive.

However, if nothing is working and the patient's condition isn't improving or is deteriorating further, you may have to make the hard decision to conclude the resuscitation attempt.