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Pulseless Electri CAL Activity

This document provides information on pulseless electrical activity (PEA) arrest, including: 1) It describes the primary and secondary ABCD survey approach for PEA arrest, focusing on establishing airway, breathing, circulation, and defibrillation. 2) It lists and describes several potential causes of PEA arrest, such as cardiac tamponade, tension pneumothorax, and pulmonary embolism. Treatment approaches for these conditions are also outlined. 3) Guidelines are provided for management of PEA arrest, including performing high-quality CPR, establishing intravenous access, administering epinephrine and atropine, and searching for reversible causes.

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Kar Twentyfive
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647 views51 pages

Pulseless Electri CAL Activity

This document provides information on pulseless electrical activity (PEA) arrest, including: 1) It describes the primary and secondary ABCD survey approach for PEA arrest, focusing on establishing airway, breathing, circulation, and defibrillation. 2) It lists and describes several potential causes of PEA arrest, such as cardiac tamponade, tension pneumothorax, and pulmonary embolism. Treatment approaches for these conditions are also outlined. 3) Guidelines are provided for management of PEA arrest, including performing high-quality CPR, establishing intravenous access, administering epinephrine and atropine, and searching for reversible causes.

Uploaded by

Kar Twentyfive
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPT, PDF, TXT or read online on Scribd
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PULSELESS

ELECTRI
CAL
ACTIVITY
KAREN P. IDANG RN
Learning Objectives:

 Be able to apply ACLS approach


(primary and secondary ABCD survey)
 Be able to establish the critical system:
airway, breathing, circulation,
defibrillation
 Be able to state 10 causes of PEA arrest
 Case Scenario:
A 55 yr. old man walks into the ER
complaining of severe chest pain and
abdominal pain. He is placed on a
stretcher and begins to remove his
clothes. Just as the ER-nurse starts to
attach the monitor leads, he falls back
unconscious on the stretcher.
 ECG: PEA? Sinus Rhythm?
 ECG: PEA?
sinus tachycardia with no pulse?
 ECG: PEA? Asystole?
 ECG: PEA? Idioventricular Rhythm?
EMD?
 ECG: PEA? Junctional Rhythm?
Pulseless Electrical
Activity
PRIMARY ABCD survey
A: Airway = open the airway

B: Breathing = provide positive pressure


ventilation

C: Circulation = give chest compressions

D: Defibrillation = not indicated


Pulseless Electrical
Activity
SECONDARY ABCD survey
A: Airway = place device ASAP
B: Breathing = confirm airway device by PE, tube
confirmation, secure airway device to prevent
dislodgement, confirm effective oxygenation and
ventilation
C: Circulation = identify rhythm, establish IV
access, administer drugs appropriate for rhythm
condition, assess for occult blood flow (“pseudo-
EMD”)
D: Differential = search for and treat identified
causes
Pulseless Arrest

 BLS algorithm: call fro help, give CPR


 Give oxygen when available
 Attach monitor/defibrillator when
available
Pulseless Arrest
 Check Rhythm: Shockable Rhythm?
ASYSTOLE/PEA (not shockable)
> CPR immediately for 5 cycles
> When IV/IO available, give vasopressor
Epinephrine 1mg
Repeat every 3 to 5 mins OR
may give 1 dose of Vasopressin 40 U
IV/IO to replace 1st or 2nd dose of epinephrine
> Consider Atropine 1mg IV/IO for
asystole or slow PEA rate, repeat
every 3 to 5 min (up to 3 doses)
Pulseless Arrest: During
CPR
 Push hard and fast (100/min)
 Ensure full chest recoil
 Minimize interruptions in chest compression
 One cycle of CPR: 30 compressions then 2
breaths, 5 cycles = 2 minutes
 Avoid hyperventilation
 Secure airway and confirm placement
Pulseless Arrest: During
CPR
= After an advanced airway is placed,
rescuers no longer deliver “cycles” of
CPR. Give continuous chest
compressions without pauses fro
breaths. Give 8 to 10 breaths/min. Check
rhythm every 2 minutes
 Rotate compressors every 2 minutes
with rhythm checks
Pulseless Arrest: During
CPR
 Search for Reversible causes: 5H’s & 5T’s
5H’s = Hypovolemia, Hypoxia, Hydrogen ions
(ACIDOSIS), Hyper – Hypo kalemia,
Hypothermia, Hypoglycemia

5T’s = Tablets/Toxins, Tamponade (cardiac),


Tension Pneumothorax, Thrombosis (ACS
or Pulm. Embolism), Trauma
Cardiac Tamponade

 Pathophysiology:
> Impairment of ventricular diastolic filling
caused by pressure of pericardial sac
and bulging of ventricular septum into the
LV. Stroke volume and cardiac output
falls
Cardiac Tamponade
Cardiac Tamponade
 Clinical Signs:
> pulsus paradoxus
> pericardial friction rub may be present
> heart size on Xray may be normal or
enlarged
> Echocardiogram
> ECG: electrical alternans
Cardiac Tamponade
CXR: widened
mediastinum
Cardiac Tamponade

CT Scan:
Cardiac Tamponade
ECG: electrical alternans
2D ECHO:
2D ECHO: M-mode
Cardiac Tamponade

 Clinical Manifestations:
> CVP elevated
> early rapid ventricular filling inhibited
> intracardiac pressures equalize
during diastole
> pulsus paradoxus usually present
Cardiac Tamponade

 Pressures in Cardiac Tamponade:


Cardiac Tamponade

 Pericardiocentesis:
> therapeutic and diagnostic
procedure in which fluid is removed
from the pericardium, the sac that
surrounds the heart.
Pericardiocentesis
 General Principles: (update)
> As of 2000: ECG used to guide
pericardiocentesis

> Direct subxyphiod techniques only used


in medical emergency

> ECG and hemodynamic monitoring

> Full resuscitation equipment available


Pericardiocentesis

 Indications:
> immediate threat to life
> severe hemodynamic impairment
> fall in systolic blood pressure
Pericardiocentesis

 Technique:
> patient in supine position upper
torso elevated
> ECG: limb leads attached to patient
> use Echo guided procedure
> Subxyphoid approach
> Continuous aspiration
Pericardiocentesis

 Equipment:
> 16g needle, short bevel, large bore
> 30 or 50cc syringe
> Echo or ECG guided
> local anesthetic
> sterile supplies
Pericardiocentesis
Pericardiocentesis
Pericardiocentesis

 ECG guided needle advancement:


Pericardiocentesis Echo
Guided
Pericardiocentesis

 Complications:
> Cardiac arrhythmia
> laceration of myocardium or
coronary arteries
> injection of air into cardiac
chambers
> hydrothorax or pnuemothorax
> Hemorrhage from laceration
Pneumothorax

 Definition:
> entry of air into pleural space
causing lung collapse
Tension Pneumothorax
 Definition:
> air under pressure
> venous return inhibited
> mediastinum displaced
> vena cava kinked
> cardiac output decreased
> cardiovascular collapse developed
Tension Pneumothorax
 Clinical manifestation:
> spontaneous breathing
> respiratory distress
> florid face
> tracheal deviation
> distended neck veins
> tachycardia
> hypotension
Tension Pneumothorax
CXR: pleural
margin with partial
lung collapse

collapsed lung
Tension Pneumothorax
CT Scan:
Tension Pneumothorax
Tension Pneumothorax

 Treatment:
> provide treatment as soon as
diagnosis is apparent to prevent
cardiovascular collapse and cardiac
arrest
> do not wait fro XRAY confirmation
> use large bore needle tap
Tension Pneumothorax
 Equipment:
> 14g large bore needle
> sterile materials
 Technique:
> cleanse overlying skin
> insert needle at 2nd or 3rd ICS-MCL,
over top of rib
> leave catheter in pleural space open to
air then place on water sealed
bottle
Tension Pneumothorax
Tension Pneumothorax
 Complications:
> misdiagnosis – pneumothorax created
> lung laceration
> internal mammary or intercostal
vessel laceration
> pneumothorax
Critical Actions - PEA

 Perform all steps in ABCD survey and


CPR
 Operate monitor
 Recognize PEA
 Direct intubation and assess ventilation
 Direct IV access
Critical Actions - PEA

 Assess patient and name conditions


causing PEA
 Determine management
 Administer fluid challenge
 Administer epinephrine
 Administer Atropine if rate is low
Common Perils and
Pitfalls
 Not assessing patient
 Not considering possible causes
 Only treating with epinephrine
 Not trouble shooting ventilation/intubating
patient
 Not giving volume infusion
 Defibrillation
 Not performing chest compressions
Rhythms to Learn

 Electromechnical dissociation
 Idioventricular rhythm
 Pulseless asystole
 Bradyasystole rhythm
 Ventricular junctional escape
 Pseudo EMD
Thank you!

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