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A Simplified and Structured Teaching Tool for the Evaluation and Management of Pulseless Electrical Activity

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A Simplified and Structured Teaching Tool for the Evaluation and Management of Pulseless Electrical Activity R e v i e w Med Princ Pract 2014;23:1–6 Received: February 27, 2013 DOI: 10.1159/000354195 Accepted: July 2, 2013 Published online: August 13, 2013 A Simplified and Structured Teaching Tool for the Evaluation and Management of Pulseless Electrical Activity a b a, c L a s z l o L i t t m a n n Devin J. Bustin Michael W. Haley a b c D e p a r t m e n t s o f Internal Medicine and Emergency Medicine, and Pulmonary and Critical Care Consultants, Carolinas Medical Center, Charlotte, N.C., USA K e y W o r d s Introduction Pulseless electrical activity · Cardiopulmonary resuscitation · Electrocardiogram · Echocardiogram Patients with pulseless electrical activity (PEA) ac- count for up to 30% of cardiac arrest victims [1, 2] . The survival rate of patients with PEA is much worse than that A b s t r a c t of cardiac arrest patients with shockable rhythms [1, 3] . Cardiac arrest victims who present with pulseless electrical Studies suggest that cause-specific treatment of PEA is activity (PEA) usually have a grave prognosis. Several condi- more effective than general treatments offered by ad- tions, however, have cause-specific treatments which, if ap- vanced cardiac life support (ACLS) guidelines such as plied immediately, can lead to quick and sustained recovery. cardiac massage, epinephrine and vasopressin [4] . High- Current teaching focuses on recollection of numerous con- er-dose epinephrine has actually been shown to be associ- ditions that start with the letters H or T as potential causes of ated with worse outcomes [5] . Both the European and PEA. This teaching method is too complex, difficult to recall American ACLS guidelines, therefore, stress the signifi- during resuscitation, and does not provide guidance to the cance of quickly finding and addressing the cause of PEA most effective initial interventions. This review proposes a [6, 7] . Memory aids list numerous conditions whose Eng- structured algorithm that is based on the differentiation of lish names start with the letters H or T as potentially treat- the PEA rhythm into narrow- or wide-complex subcatego- able causes of PEA ( fig. 1 ) [6, 7] . Studies, however, have ries, which simplifies the working differential and initial shown that during cardiopulmonary resuscitation it is treatment approach. This, in conjunction with bedside ultra- difficult to recall up to 13 causes of PEA [8] . Moreover, sound, can quickly point towards the most likely cause of even if such a list can be generated, the ACLS does not PEA and thus guide resuscitation. © 2013 S. Karger AG, Basel provide guidance on the relative likelihood of the specific causes, nor does it offer suggestions on how to individual- ize treatments based on simple initial findings. These limitations of current ACLS guidelines have been recognized and attempts have been made to sim- © 2013 S. Karger AG, Basel Laszlo Littmann, MD, PhD 1011–7571/14/0231–0001$39.50/0 Department of Internal Medicine Carolinas Medical Center E-Mail [email protected] " is is an Open Access article licensed under the terms of the P.O. Box 32861, Charlotte, NC 28232 (USA) www.karger.com/mpp Creative Commons Attribution-NonCommercial 3.0 Un- E-Mail Laszlo.Littmann @ carolinashealthcare.org ported license (CC BY-NC) (www.karger.com/OA-license), applicable to the online version of the article only. Distribu- Downloaded by: 208.69.133.20 - 12/20/2013 2:44:16 PM tion permitted for non-commercial purposes only. FREQUENTLY LISTED PEA – EVALUATION CAUSES OF PEA (Hs & Ts) QRS NARROW QRS WIDE MECHANICAL (RV) PROBLEM METABOLIC (LV) PROBLEM •Hypovolemia •Toxins Color version available online Color version available online •Cardiac tamponade •Severe •Hypoxia •Tamponade •Tension PTX hyperkalemia •Hydrogen ion •Tension PTX •Mechanical •Sodium-channel blocker toxicity –acidosis •Thrombosis hyperinflation •Pulmonary embolism •Hyperkalemia – coronary AGONAL RHYTHM •Hypokalemia •Thrombosis ACUTE MI ACUTE MI •Hypothermia –pulmonary Myocardial rupture Pump failure • (Hypoglycemia) • (Trauma) BEDSIDE US: LV HYPERDYNAMIC LV HYPOKINETIC OR AKINETIC PSEUDO-PEA TRUE PEA Fig. 1. Causes of PEA listed by European and American guidelines. Fig. 2. New classification of PEA based on its initial electrocardio- Hypoglycemia and trauma have been removed from the most re- graphic manifestation. LV = Left ventricular; PTX = pneumotho- cent ACLS guidelines [6, 7] . PTX = Pneumothorax. rax; US = ultrasound; RV = right ventricular. plify the evaluation of patients who present with cardiac or outflow obstruction, whereas wide-complex PEA is arrest due to PEA [9, 10] . There were also attempts to use typically due to a metabolic problem or ischemia and left the electrocardiogram (ECG) and bedside echocardio- ventricular failure. Wide-complex PEA may also indicate gram to guide the diagnosis and management of PEA agonal rhythm. [10–16] . Over the last few years we have developed a The four most common mechanical causes of PEA ar- teaching tool that simplifies the diagnostic approach by rest include cardiac tamponade, tension pneumothorax, differentiating narrow- and wide-complex rhythms on mechanical hyperinflation and pulmonary embolism initial telemetry (QRS duration <0.12 and 0.12 s, respec- ( fig. 2 ). The clinical scenario can usually help navigate tively), and by eliminating those diagnoses which rarely between these causes. Jugular venous distension and if ever cause PEA. Our algorithm does not apply in the muffled heart sounds suggest tamponade. Rib fracture, specific trauma setting. This algorithm has not been sys- severe emphysema, positive pressure ventilation and hy- tematically tested but is supported by scientific and clini- perexpanded chest indicate pneumothorax, mechanical cal principles and by a thorough review of the literature. hyperinflation or auto-PEEP [17, 18] . Cancer history and deep venous thrombosis suggest pulmonary embolism. In all of these cases cardiac ultrasound usually shows pre- The New PEA Algorithm: Diagnostic Aspects served or even hyperdynamic left ventricular function in- dicative of pseudo-PEA ( fig. 2 ) [10–14] . A collapsed right The multiple Hs and Ts that are frequently quoted as ventricle suggests inflow obstruction from tamponade, possible causes of PEA are listed in figure 1 . It seems ob- pneumothorax or hyperinflation. A dilated right ventri- vious that recollection of these can be near impossible in cle, on the other hand, indicates possible pulmonary em- the acute setting. Our simplified algorithm that focuses bolism. Thoracic ultrasonography may also help in direct on differentiation between narrow or wide QRS complex- pleural assessment and in the diagnosis of pneumotho- es is shown in figure 2 . This should be an easy distinction rax. that can be discerned by simply looking at the telemetry Wide-complex PEA usually suggests a metabolic prob- monitor during resuscitation. The general assumption is lem such as severe hyperkalemia with or without meta- that narrow-complex PEA is generally due to a mechani- bolic acidosis, or sodium channel blocker toxicity ( fig. 2 ) cal problem frequently caused by right ventricular inflow [19, 20] . Again, the clinical scenario is usually helpful: in 2 Med Princ Pract 2014;23:1–6 Littmann /Bustin /Haley DOI: 10.1159/000354195 Downloaded by: 208.69.133.20 - 12/20/2013 2:44:16 PM PEA – MANAGEMENT PEA – MANAGEMENT QRS NARROW WIDE OPEN PHARMACOLOGIC QRS WIDE MECHANICAL (RV) PROBLEM FLUIDS, PLUS: MANAGEMENT METABOLIC (LV) PROBLEM Color version available online Color version available online •Cardiac tamponade PERICARDIOCENTESIS IV CALCIUM •Severe •Tension PTX NEEDLE DECOMPRESSION CHLORIDE hyperkalemia • Mechanical VENTILATOR hyperinflation MANAGEMENT IV SODIUM •Sodium-channel BICARBONATE blocker toxicity •Pulmonary embolism THROMBOLYSIS BOLUSES Fig. 3. Treatment recommendations for narrow-complex PEA. Fig. 4. Treatment recommendations for wide-complex PEA. IV = PTX = Pneumothorax: RV = right ventricular. Intravenous; LV = left ventricular. patients with critical illness, sepsis, shock or renal failure, An important question is whether this simplified al- the diagnosis of wide-complex PEA is usually hyperkale- gorithm covers all important causes of PEA? We believe mia. Identification of an arteriovenous fistula or dialysis that it does. A recent thorough review of the PEA litera- catheter also suggests hyperkalemia. In patients who were ture by Desbiens [9] and our independent review did not ‘found down’ or who present following ingestion or sui- find any evidence that hypoxemia, hypokalemia or hypo- cide attempt, the cause of wide-complex PEA is almost glycemia presents primarily with PEA. Hypothermia is always sodium channel blocker toxicity [21] . In wide- not listed in our new algorithm, but there the clinical complex PEA, a metabolic or ischemic cause is supported picture is usually quite obvious. Of ‘toxins’, the initial by the echocardiographic observation of left ventricular presentation of β-blocker, calcium channel blocker and hypokinesis or standstill ( fig. 2 ). Other possible causes of digitalis toxicity is almost always hypotension, sinus bra- wide-complex PEA include a mechanical etiology with dycardia, sinus arrest or atrioventricular block [26, 27] . preexisting aberrancy or pulmonary embolism – a me- Some of these do progress to PEA but by that time the chanical cause that can be associated with complete right diagnosis is usually well established [28–30] . Standard bundle branch block. In these cases too, bedside ultra- treatments are available for these conditions [26, 31]
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