PEA
How to maximise our resuscitation efforts, even in resource-poor centers
Did you know that in one study 58% of patients thought to be in PEA, had coordinated cardiac motion?
It only takes a small shift in what we do to make a difference. Watch the lecture and see how you can change your approach, to incorporate some of what it discusses.
A few changes can make a big difference
Use a phased array probe
Aim to get a good cardiac view, with a subcostal approach:
- You can perform the ultrasound whilst CPR is still being performed
- You can even guide the compressions for maximal effect
- This view may only be successful in 50% of cases, due to body habits or increased abdominal pressure during compressions
- If unable to get a view in this way, you can try to a parasternal long axis view during the pulse check
Or if this is not possible, a simple shift is to use the Vascular probe
- Keep this on the femoral vessels whilst CPR is progressing
- During the pulse check pause, keep the probe in place and see if there is femoral arterial pulsation. If positive, there must be cardiac motion
What is PEA?
PEA is becoming a more common presentation in out of hospital cardiac arrests (1). Our diagnosis of PEA is based on an organised rhythm being present but no pulse.
What if there is no pulse, but there is cardiac activity. Not a little flutter of the valves, but actual activity?....but still no pulse? Thus has been called pseudoPEA……… but it’s not pseudo-anything, it is shock.
Why is this important?
PEA has a very poor prognosis at best 2% survival to neurologically intact hospital discharge. Shock, has a potential better survival, up to 5 fold better.
Finding a pulse depends on many factors:
- Operator experience
- Decreased body temperature
- Obesity
- Low cardiac output
Trying to find a pulse may delay CPR, just as it will if there is a false positive finding. A false negative finding may lead to CPR that is asynchronous with natural cardiac motion and lead to harm(2).
Why is it so important to look for cardiac contractions?
An organised rhythm with no contractions is PEA. However an organised rhythm with contractions and no pulse is profound shock. The FEEL Study (3) found that 58% of patients thought to be in PEA had coordinated cardiac motion. ECHO resulted in a change in management in 78% of cases.
Use of ultrasound to detect pulses is not inferior to manual pulse checks (4)
Finding the pulse with ultrasound(4):
- Was not slower with manual palpation
- Required fewer attempts
- Had less variability in times.
We must apply ultrasound to our everyday cardiac resuscitation, when we suspect PEA. This can be done quickly and effectively.
References
- Andrew E et al. Outcomes following out of hospital cardiac arrest with an initial cardiac rhythm of asystole or pulseless electrical activity in Victoria, Australia. Resuscitation 85(2014). 1633-1639.
- Hogan T.S. External cardiac compressions may be harmful in some scenarios of pulseless electrical activity. Medical Hypothesis Vol 79 Issue 4. October 2012. 445-447.
- Breitkreutz R et al. Focused echocardiographic evaluation in life support and peri-resuscitation of emergency patients: A prospective trial.Resuscitation 2010;81:1527-1533.
- Badra K et al. The POCUS pulse check: A randomised controlled crossover study comparing pulse detection by palpation versus by point of care ultrasound. Resuscitation 139(2019) 17-23.
- Flato UAP, et al. Echocardiography for prognostication during the resuscitation of intensive care unit patients with non-shockable rhythm cardiac arrest. Resuscitation. 2015;92:1-6.