Acute Care MedicineEmergency MedicineResuscitationSMACCUltrasoundA Revised Algorithm for PEA Cardiac Arrest: Haney Mallemat

A Revised Algorithm for PEA Cardiac Arrest: Haney Mallemat

Haney Mallemat discusses the treatment for PEA cardiac arrest.

Patients who present with pulseless electrical activity (PEA) arrest have a high mortality. The treatment of PEA requires finding and reversing the underlying cause; therefore a simple and rapid approach is required.

Traditionally we were taught to use the H’s and the T’s, but this diagnostic tool is cumbersome and of questionable utility overall.

Haney discusses the problems with the traditional H’s and T’s as well as focusing on newer approaches to PEA arrest. Haney makes the point that PEA is not a diagnosis, but a ‘waste basket term’ for a lot of possible diagnoses.

Rather than assisting a clinician in the assessment and treatment of a patient, it acts on to lead to pontification.

To that end, Haney wants us to do away with the H’s and T’s. The problem with the algorithm of diagnosing a PEA, as Haney explains, is the reliance on feeling a pulse. It lacks sensitivity and specificity, largely linked to using fingers.

They should not be used in resuscitation scenarios – as the guidelines say we should.

Haney makes the point that despite all the advances in medicine, resuscitation has stayed essentially the same for decades.

He describes two ways in which he thinks we can advance our care.

The first involves the QRS complex. Ask the question – is the QRS complex narrow or wide. Narrow (< 0.12 seconds) leads you to consider mechanical problems, such as tension pneumothorax or tamponade. If it is wide (> 0.12 seconds), then consider metabolic problems such as hypokalaemia.

If the QRS is narrow, and you are thinking a mechanical problem then there is electrical activity, and the heart is still beating underneath. The step should be to use ultrasound immediately to find the focused cause. If it is wide, and you are considering metabolic causes, this is more aligned with a true PEA. Calcium bicarbonate should be considered in the first instance.

Haney describes the limitations with the algorithm that includes the trauma patient or those with underlying cardiac conditions.

Next Haney describes a second algorithm – PREM (pulseless with rhythm and echo motion) and PRES (pulseless with a rhythm and echo standstill). The use of ultrasound is central to this pathway. In PREM the left ventricle is not strong enough to produce a pulse. Does this patient get adrenaline or chest compressions?

Haney discusses the options. In PRES there is electrical activity, but the heart is not squeezing. Maybe these people should get adrenaline and compressions!

The ECG should still play a part in this algorithm. Haney puts it all together for you and takes you through the algorithm he uses when faced with a patient with PEA.

He includes some tips for using the ultrasound probe during cardiac arrest resuscitation scenarios.

A Revised Algorithm for PEA Cardiac Arrest: Haney Mallemat

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Haney Mallemat

Dr. Haney Mallemat is board certified in Emergency Medicine, Internal Medicine, and Critical Care Medicine and works in the Emergency Department and Intensive Care Unit in Baltimore Maryland. He has lectured both nationally and internationally, and has contributed to several Emergency Medicine and Critical Care podcasts. He is a firm believer in the benefits of bedside ultrasound for better patient care. He also uses ultrasound to help education medical students, residents, fellows, nurses, and mid-level providers. He was awarded the Department of Emergency Medicine “Outstanding Teaching Award” in 2012, in 2013, and in 2015.