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Pulseless electrical activity (PEA)

Also called PEA.

Any organized rhythm with no pulse. This strip would be a normal rhythm if the patient had a pulse, which is the point: PEA is found with your fingers, not on the paper. Not shockable, it is a hunt for the cause.

A 6-second EKG rhythm strip showing Pulseless electrical activity (PEA).
Pulseless electrical activity (PEA), 6 seconds of strip. Each small box is 0.04 seconds and each large box is 0.20 seconds.

How to identify Pulseless electrical activity (PEA)

Rate
Any
Rhythm
Any organized rhythm
P waves
May look normal
PR interval
May look normal
QRS
May look normal
Clincher
An organized rhythm with no pulse. You find PEA with your fingers, not on the paper.
Common causes
The H's and T's: hypovolemia, hypoxia, hydrogen ion (acidosis), hypo- or hyperkalemia, hypothermia, tension pneumothorax, tamponade, toxins, coronary or pulmonary thrombosis.

Treatment by certification level

Open your level. Treat the patient, not the strip.

Paramedic

Non-shockable arrest.

  • High-quality CPR. Never shock asystole or PEA.
  • Epinephrine 1 mg IV/IO as early as feasible, then every 3-5 minutes.
  • No antiarrhythmic: there is no rhythm for one to act on.
  • Hunt for the cause: the H's and T's.
  • Two-minute cycles with a rhythm check. If it turns shockable, switch to the shock path.
  • Waveform capnography. An abrupt rise in EtCO2 is often the first sign of ROSC.
  • Blood or fluid loss points to hypovolemia: a rapid crystalloid bolus, not another round of the routine drugs.
AEMT

Cardiac arrest: CPR, the AED, epinephrine.

  • High-quality CPR and the AED, exactly as at the EMT level. After every analysis, shock or no shock, compressions resume immediately.
  • IV or IO access.
  • Epinephrine 1 mg IV/IO as early as feasible, then every 3-5 minutes.
  • Supraglottic airway and waveform capnography. EtCO2 under 10 mmHg means fix the compressions; an abrupt sustained rise suggests ROSC, confirmed at the scheduled rhythm check.

Manual defibrillation and antiarrhythmics (amiodarone, lidocaine) are Paramedic level. The AEMT's electrical therapy is the AED.

EMT

Cardiac arrest: CPR and the AED.

  • High-quality CPR, starting with compressions.
  • AED on as soon as it arrives.
  • The AED will not advise a shock for this rhythm. Resume compressions immediately.
  • Two minutes of CPR, then let the AED reanalyze. Check a pulse only at that scheduled rhythm check.

Could you pick out Pulseless electrical activity (PEA) on a fresh strip? See how many rhythms you can identify in one minute.

Try the 60-second rhythm challenge