1.8. PULSELESS ELECTRICAL ACTIVITY (Cardiac Arrest)
The absence of a detectable pulse and the presence of some type of electrical
activity other than ventricular tachycardia or ventricular fibrillation define this group of
dysrhythmias. These rhythms can represent the last electrical activity of a dying
myocardium, or they may indicate specific disturbances. Wide-complex PEA can
appear as a result of severe hypovolemia, hypoxia, acidosis, hyper/hypokalemia,
hypothermia, or toxic overdose (tricyclic antidepressants, beta-blockers, calcium
channel blockers, digitalis). Treatment of PEA may include suspecting and treating
other specific possible causes, such as cardiac tamponade, tension pneumothorax,
coronary thrombosis (ACS), and pulmonary embolism.
ASSESSMENT / TREATMENT PRIORITIES
1. Ensure scene safety and maintain appropriate body substance isolation
precautions.
2. Determine unresponsiveness, absence of breathing and pulselessness.
3. Maintain an open airway with appropriate device(s), remove secretions and
vomitus, initiate CPR (“push hard, push fast”, limit interruptions), and administer
oxygen using appropriate oxygen delivery device, as clinically indicated.
4. Continually assess Level of Consciousness, ABCs and Vital Signs.
5. Obtain appropriate S-A-M-P-L-E history related to event, including possible
ingestion or overdose of medications, specifically calcium channel blockers, betablockers
and/or digoxin preparations.
6. Initiate transport as soon as possible, with or without ALS.
TREATMENT
BASIC PROCEDURES
1. EARLY DEFIBRILLATION.
a. Perform CPR until AED device is attached and operable.
b. Use AED according to the standards of the American Heart Association or as
otherwise noted in these protocols and other advisories.
c. Resume CPR when appropriate.
2. Activate ALS intercept, if deemed necessary and if available.
3. Initiate transport as soon as possible with or without ALS
4. Notify receiving hospital.
INTERMEDIATE PROCEDURES
1. Activate Paramedic intercept, if deemed necessary and if available.
2. ALS STANDING ORDERS
Provide advanced airway management.
Initiate IV Normal Saline (KVO).
Consider a 250 mL bolus of IV Normal Saline, or titrate IV to patient’s
hemodynamic status.
Consider underlying causes for PEA
PARAMEDIC PROCEDURES
1. ALS-P STANDING ORDERS
Provide advanced airway management
Initiate IV Normal Saline (KVO).
Consider a 250 mL bolus of IV Normal Saline, or titrate IV to patient’s
hemodynamic status.
Consider and treat underlying causes for PEA:
• hypothermia: initiate 2 large bore IVs (warm) normal saline
• drug overdose: see specific toxicology protocol
• pneumothorax: perform needle chest decompression
e. If cause is unknown and PEA persists:
• Epinephrine 1:10,000 1 mg IV/IO Push every 3-5 minutes. Epinephrine
may be given via Endotracheal Tube if IV/IO is not established. (2 - 2.5
mg of Epinephrine 1:1,000 is preferred (ET) every 3-5 minutes).
• If electrical bradycardia (less than 60 Beats per minute) exists, administer
Atropine 1 mg IV/IO Push every 3-5 minutes to a total of 3 mg. Atropine
may be given via Endotracheal Tube if IV is not established. (Atropine 2.0
mg via ET tube to maximum 6.0 mg)
2. Contact MEDICAL CONTROL. The following may be ordered:
a. Additional Normal Saline Fluid bolus(es) as indicated.
b. Sodium Bicarbonate 1 mEq/kg IV push
