Pulseless Electrical Activity (PEA) Algorithm

What is Pulseless Electrical Activity (PEA)?

Pulseless electrical activity, also commonly referred to as PEA, is a condition where the electrical activity of the heart isn’t accompanied by a palpable or effective pulse. Healthcare providers need to find the potential cause and correct it, which will hopefully restore the patient’s pulse.

Pulseless electrical activity is not a specific rhythm. Instead, it’s a term used to describe any organized electrical activity – but excluding VFib or asystole — on an ECG or cardiac monitor that is associated with no palpable pulses.

Pulsations can be detected by an arterial waveform or Doppler study. However, pulses are not palpable. The rate of electrical activity may be slow (which is most common), normal, or fast. Very slow pulseless electrical activity can also be referred to as agonal.

When a patient is in PEA, the ECG monitor can display normal or wide QRS complexes, as well as other abnormalities, which include:

  • Low or high-amplitude T-waves
  • Prolonged PR and QT intervals
  • Atrioventricular disassociation
  • Complete heart block
  • Ventricular complexes without P-waves

ACLS providers must remember to assess the patient’s monitored rhythm and note the rate and width of the QRS complexes. PEA can be caused by reversible conditions easily remembered as the H’s and T’s, which you’ll see below.

Causes of Pulseless Electrical Activity (PEA)

It’s always important to treat the patient’s symptoms, rather than rely on the ECG readout alone. Underlying and treatable causes for pulseless electrical activity include:

  • Pulmonary thrombosis
  • Coronary thrombosis
  • Tension pneumothorax
  • Cardiac tamponade
  • Hypovolemia
  • Hyperkalemia
  • Hypoxia
  • Hydrogen ion (acidosis)

It’s important to rule out any of the treatable H’s and T’s as underlying causes for pulseless electrical activity to correct the mechanical disassociation that could be causing the patient’s cardiac arrest.

The ECG interpretation for a patient exhibiting signs of PEA could be the same as normal sinus rhythm. For this reason, treating the patient’s symptoms, particularly when it comes to pulseless electrical activity, is vitally important. Rather than merely reacting to and relying on the rhythms that are being displayed on the ECG monitor.

Signs and Symptoms of Pulseless Electrical Activity (PEA)

A patient with PEA will be unconscious with no pulse or normal breathing. Pulseless electrical activity leads to a loss of cardiac output and discontinues blood supply to the brain. The skin may appear pallor due to a lack of oxygen in the blood.

ACLS providers should make sure to check for a pulse at the carotid artery. They can also check for heart sounds by using a stethoscope for no more than 10 seconds.

Diagnosis of Pulseless Electrical Activity (PEA)

An ECG/EKG is capable of distinguishing pulseless electrical activity from other causes of cardiac arrest.

The absence of a patient’s pulse confirms a clinical diagnosis of cardiac arrest. However, in PEA, there is no pulse with orderly cardiac electrical activity similar to normal sinus, which is not a typical cardiac arrest ECG rhythm like asystole (seen as a flat line on the monitor), ventricular fibrillation, or ventricular tachycardia.

Treatment for Pulseless Electrical Activity (PEA)

Unless you can quickly identify and treat the cause of pulseless electrical activity, the rhythm will likely deteriorate to asystole.

The adult cardiac arrest algorithm is the most important algorithm for adult resuscitation. This algorithm outlines all of the assessment and management steps ACLS providers will need to know for all pulseless patients who do not initially respond to basic life support interventions, including the first shock from an AED.

The algorithm consists of the two pathways for a cardiac arrest:

Common medications used to treat VFib or pulseless V-tach include:

Common medications used to treat asystole and pulseless electrical activity include:

  • Epinephrine
  • Other medications, depending on the cause of the asystole or PEA arrest

Treatment for pulseless electrical activity involves high-quality CPR, airway management, IV or IO therapy, and the appropriate medication therapy. The primary medication is 1mg epinephrine 1:10,000 every 3-5 minutes via rapid IV or IO push.