EDECMO # 13 – Does Pseudo-PEA Exist and What Should You Do About It

This is the first episode where all three of the EDECMO boys are together–yeah! Today we talk about a bunch of PEA stuff. Scott proposes 2 new terms to bring us into the modern era: PREM-pulseless with a rhythm and echocardiographic motion PRES-pulseless with a rhythm and echocardiographic standstill Joe asks why we shouldn't just treat the latter like asystole, and he's probably right. But what of the former? What should we do with that? Listen to the episode.  

Jim Manning's talk at GSA HEMS

On Youtube

Here's the Littmann Article on PEA

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

Update

Our friend Gregor Posen performed this excellent Pseudo-PEA (PREM) Paper

 Bibliography

In this episode, Joe was “Orating via the Anus” while Zack and Scott took a more evidence-based approach:

 

Update

This new study seems to demonstrate that stratification by ecg width may not be evidence-based

 

TrackBacks

“PEA is just a bunch of BULLSHIT!”  Joe talks about the FALLACY OF PEA on the ER Cast podcast with Rob Orman…  

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SAMGHALI
Guest
SAMGHALI

Hey guys- awesome cast! Glad to hear you all on together… could feel the love from here, ha! My thoughts: The paper itself is Interesting & thought-provoking. It brings to light some of what I would consider golden rules of codes in general: One of the greatest/ most important things we can be doing during code is to figure out the etiology & try to reverse. (not just true for PEA) Cause-specific treatments are always better than rote ACLS Clinical picture (history, physical, meds, etc) should always be taken into context Echo is an integral, indispensable tool to accomplishing #1–… Read more »

Joseph Bellezzo
Editor

Sam, as expected…another super thoughtful comment. I can’t really disagree with any of your thoughts here. But…(and Scott will disagree with me)…I have two thoughts: 1. Sadly, for many practitioners, PEA = chest compressions and epi 1 mg BEFORE they run the H’s and T’s. Its knee-jerk. That needs to stop, hence the rant. So whether you call it PRE-M or “profound shock” (as I prefer), you should stop and think BEFORE acting. “PEA” is a description, not a rythm. For VF, VT, or brady, I know exactly what to do. Calling it PEA can cause harm. And once you’ve… Read more »

Jason Jones
Guest
Jason Jones

While I am sure the term “PEA” was meant with best of intentions, its ambiguity may have resulted in many unnecessary deaths in the out of hospital setting. If we look at national data, it becomes clear that resuscitation efforts are being terminated in the field more often (19% of bystander witnessed PEA from 2013-2016) and this trend is likely to increase in the coming years as more EMS agencies adopt a ROSC or terminate approach. A dichotomous treatment approach may not be appropriate in the hospital setting, but may yield better results in the out-of-hospital setting. In the podcast… Read more »

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[…] EDECMO Podcast #13 Does Pseudo-PEA Exist and What Should You Do About It […]

Thomas D
Guest

Great, and opinionated rant! PREM and PRES. I like it. I think PREM needs subcategories for management: this is profound shock, but can be different types of shock, needing different treatment. And they can only be differentiated by echocardiography: PREM types: 1. “Cardiogenic shock” If we’re talking PREM with cardiogenic shock (or certain septic shocks), you’ll see a filled heart with some, but very little contraction. This patient would probably benefit from compressions. 2. “Hypovolemic shock” The other PREM is the hyperdynamic, but almost empty heart. This is a hypovolemic type shock (and also often seen in septic shock). This… Read more »

Joseph Bellezzo
Editor

Great comments Thomas. Do you think it will be possible, as Shinar hopes, to do synchronized chest compressions (where the chest compressions are done in concert with the native heart beat as visualized on TEE)?

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[…] exactly is “pseudo PEA”? The ED ECMO podcast tackles this question, and suggests a new way to think about PEA arrest. […]

Anand Swaminathan
Guest

Excellent podcast, guys. I think this is a long needed paradigm shift in the way we think about PEA with the widespread use of ultrasound. Early in my career, I was pretty anti-arterial line in these patients. The risks didn’t seem to be outweighed by the benefits. However, with a focus on ultrasound for cardiac motion and de-emphasis of the finger pulse check, early art-line makes good sense. As far as near empiric bicarbonate use, I think we should be clear on why we are giving bicarb. My understanding (correct me if I’m wrong) is that administration of sodium bicarbonate… Read more »

Joseph Bellezzo
Editor

Swami, thanks for the comments! As you know, we love the intra-arrest art-line now. 1. possible after relinquishing “control’ of the code to an RN-Code Team Leader to call out times, drugs, pulse-checks, etc. 2. Intra-Arrest hemodynamic-directed Epi dosing. (EDAP >40 maybe doesn’t need 1 mg epi) and 3. established conduit for ECMO cannulas.

Your thoughts on bicarb are right-on.

~joe

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[…] Pulseless Electrical Activity (PEA). Our current algorithms leave much to be desired in terms of PEA management. The ED ECMO crew discuss updated thoughts on PEA and using a different approach to diagnosis and […]

Walt L
Guest
Walt L

Hi Guys- long time listener, first time writer. I like what you’re doing, like what you’re saying, and am generally in agreement with you. Except for one thing: the comment that it is an “epic fail” to terminate resuscitation on PEA in the field because some of these guys may not be totally dead. I agree that in your system it probably makes sense to haul more people than not into the hospital, because you may be able to offer them something more than can be delivered on the floor of the kitchen. And that’s awesome. But the problem is… Read more »

Joseph Bellezzo
Editor

Walt. 100% Agree. One quick explanation: The “epic fail” that Zack speaks of is really the pseudo PEA case; the case of someone who actually has a beating heart and a perfusing pressure but a pulse is not appreciated. In the field its tough to be 100% sure there is truly no perfusing pressure. In the ED, we have US to guide us. But you are right…if the ER/hospital does not offer a service that cannot be done in the field, a service that makes a difference, then transport doesn’t make sense…for all the reasons you gave. My goal is… Read more »

Steve
Guest
Steve

Excellent stuff….UK Paramedic and RAT team leader

Tom Hogan/ T.S. Hogan
Guest
Tom Hogan/ T.S. Hogan

The terminology is flawed. PEA is a subset of cardiac arrest which apparently contains a subset of “Pseudo PEA which is not cardiac arrest”! The inconvenient truth is that clinical pulselessness does not reliably diagnose cardiac arrest. I have little doubt that there are significant numbers of patients with PEA due to impaired cardiac filling, and who have significant residual cardiac output, who are being harmed by having their cardiac filling further impaired by ECC which raises mean intrathoracic pressure and repeatedly compresses (approximately 50% of compressions) the heart during diastole. This is all very problematic, but there is a… Read more »

Joseph Bellezzo
Editor

EXACTLY. Thanks for comments, Tom!
~Joe

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[…] did an episode on this topic on the EDECMO podcast (ignore the ECG stratification stuff–since been […]

Stephen
Guest
Stephen

Great podcast, really interesting.

As a paeds ED specialist from the Emerald Isle, how do you think this filters into the management of PEA in kids.

Stephen
Guest
Stephen

Great podcast!

As a paediatric ED specialist from the Emerald Isle, how do you think this fits into the management of PEA in kids?

Jason Jones
Guest
Jason Jones

You stated that you’ve never seen true PEA so I thought I’d share a working theory concerning calcium. I have no idea if I’m way off the mark, but if so, perhaps some insight could be provided. Initial hypoperfusion results in hypoxia due to inadequate oxygen delivery and elevated carbon dioxide concentration due to lack of CO2 removal. Elevated CO2 concentration causes an increase in bicarbonate ions due to carbonic anhydrase activity. As bicarbonate and hydrogen ions accumulate, available ionized calcium diminishes through precipitous creation of calcium carbonate (CaCO3) and calcium bicarbonate (CaHCO3+). In myocardial cells, contraction is dependent upon… Read more »

tom fiero
Guest
tom fiero

we just had a case tonight 58 y.o. female chest pain at home arrested in the back of her car as friends drove her in. cpr immediately in parking lot Vfib, refractory. dual defibs, amio, esmolol, and TNK (i had a very suspicion for STEMI), and she converted to wide , brady, PEA with hypokinetic stunned- like cardiac motion on US. STEMI on ekg. the team felt pressured to continue chest compressions (ACLS) for pea, but i felt that it was unwise to compress a beating heart. gave push dose EPI pressors, epi and dobutamine drips, calcium as an inotrope,… Read more »