1. PEA arrest: Chest compressions aren’t enough
Susan P. Torrey, MD, FAAEM, FACEP
Associate Professor of Emergency Medicine
UMass Medical School – Baystate Medical Center

2. I have nothing to declare, but…

4. 150 patients survived PEA arrest without severe disability at 1 year
Outcomes following out-of-hospital cardiac arrest with asystole or PEA (Australia) Andrew E Resuscitation 85: , 2014
38,378 non-shockable OHCA / 10 years – 12% PEA
Survival to hospital discharge – 6%
No trend toward improved survival over 10 years
Follow-up at 1 year
Death, vegetative state or severe disability – 45%
150 patients survived PEA arrest
without severe disability at 1 year

5. PEA…what next?

8. 5H’s and 5T’s Hypovolemia Hypoxia Hyperkalemia Hypothermia
H+ ions (acidosis)
Tension pneumothorax
Tamponade
Toxins
Thrombosis (PE)
Thrombosis (MI)

9. Pulseless Electrical Activity
SCA -- >300,000 cases/year in US
Accounts for 50% of cardiovascular deaths
PEA/asystole #’s have NOT changed in 30 years
Reduction in VT/VF during same interval
Subsets
Non-cardiac (5H’s & 5T’s)
Cardiac
Primary – initial rhythm
Secondary – following shock of VT/VF

10. Factors associated with out-of-hospital cardiac arrest with PEA: population-based study Ko DT Am Heart J 177: , 2016
Toronto, , nontraumatic cardiac arrest
9,882 patients
24% PEA 26% shockable 50% asystole
Patients with PEA vs shockable rhythm
Older (age 72 vs 65)
More likely female (41% vs 22%)
More comorbid diagnoses
More recent healthcare (ED 1 month 20% vs 10%)

12. ECG patterns in early PEA Bergum D, et al. Resuscitation 104:34, 2016

13. RUSH exam Rapid Ultrasound in Shock
Cardiac
Tamponade
LV size and fx
- RV size ?PE
IVC & Lungs
IVC collapsibility
Lungs ?pneumo
Abd ?free fluid
Aorta
Legs ?DVT

14. PEA in PE thrombolysis Sharifi M, et al. Am J Emerg Med 34:1963, 2016
23 pts with PEA receiving CPR due to massive PE
Rx 50mg tPA IV push in 1 minute during CPR
Initiation of CPR to tPA was 6.5 ± 2.1 min (all IHCA)
22/23 pts - ROSC in 2 – 15 min after tPA
At 22 ± 3 months – 20 pts alive (87%)
Survivors all returned to pre-event functional capacity
Low-dose systemic tPA at 50mg is very safe
No major bleeding
Safe to administer as bolus over 1 minute

15. Causes of in-hospital cardiac arrest Bergum D, et al
Causes of in-hospital cardiac arrest Bergum D, et al. Resuscitation 87:63-68, 2015.
302 episodes over 5 years at 1000-bed hospital
Causes of arrest
Cardiac causes – 60% Hypovolemia – 8%
Hypoxia – 20% Tamponade – 6% PE – 5%
Survived to hospital discharge – 25%
VT/VF – 53%
PEA – 13%
Asystole – 17%

16. Initial rhythm in PEA (IHCA) Bergum D, et al. Resuscitation 87:63, 2015.
Total n = 302

17. If we are going to improve survival in PEA arrest…
EMS has to return to “scoop and run”
Excellent CPR and IV fluid resuscitation
Beyond ACLS – think hyperkalemia, hypoxia
Early diagnostic ultrasound and interventions

18. CPR isn’t enough, but it is important
Improved blood flow during CPR results in  survival
Mechanical CPR devices – consistency
Monitoring cardiac function during CPR
Echocardiographiy for
End-tidal CO2 > 16mmHg – predicts survival
Pharmacological interventions
Epinephrine vs. vasopressin
Atropine no longer recommended
SOS-KANTO study (2011) -  30-day survival

19. If we are going to improve survival in PEA arrest…
EMS has to return to “scoop and run”
Excellent CPR and IV fluid resuscitation
Beyond ACLS – think hyperkalemia, hypoxia
Early diagnostic ultrasound and interventions
If all else fails  ECMO in certain situations

20. VA-ECMO Cannulation Complications During CPR For cardiogenic shock
Shock after ROSC / CPR
Complications
CVA
Acute renal failure
Major bleeding

21. Extracorporeal CPR for IHCA Singal RK, et al. Can J Card 33:51, 2017
ELSO (Extracorporeal Life Support Org)
2379 cases E-CPR with 30% survival to discharge
Initiation ECMO < 30 minutes
V tach/v fib >> PEA
Age < 65 years
Bridging to:
CABG, myocardial recovery, insertion LVAD, transplant
PE, cardiotoxic OD, hypothermia

22. - - + E-CPR + Medical Management
Indications: CA refractory to ACLS of suspected reversible origin:
Cardiac, PE, toxins, hypothermia
Contraindications:
- Asystole as initial rhythm
- ETCO2 < 13
- Lactate > 13
- Prior poor prognosis
- Unavailability of team - +
Age < 65
Witnessed CA
CPR <40 min
Reversible cause
E-CPR - +
Medical
Management
Singal R, at al. Can J Card 2017

23. Summary PEA is a spectrum of disease CPR must be very good
Attempt IV fluid resuscitation
Early identification of reversible causes
Decrease pre-hospital times
± rhythm analysis
Ultrasound evaluation – RUSH
ECMO for a select group