The unresponsive patient in the emergency department is foun...

Category: Physiological Adaptation
Difficulty: 6

Topics: Cardiovascular Crisis Management Medication and Blood Products

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Thrombosis and toxins
Hypovolemia and tamponade
Hypovolemia and hypoxia
Hypovolemia and trauma

Rationale

Hypovolemia and hypoxia are extremely common in US emergency departments. These etiologies should be at the top of the differential when evaluating pulseless electrical activity (PEA). In fact, they are so common that people in PEA are treated for hypovolemia (fluid resuscitation) and hypoxia (supplemental oxygen) almost reflexively. Other causes of PEA are shown in the table below.

Potential Cause	How to Identify	Treatments
Hypovolemia	Rapid heart rate and narrow QRS on ECG; other symptoms of low volume	Infusion of normal saline or Ringer's lactate
Hypoxia	Slow heart rate	Airway management and effective oxygenation
Hydrogen ion excess (acidosis)	Low amplitude QRS on the ECG	Hyperventilation; consider sodium bicarbonate bolus
Hypoglycemia	Bedside glucose testing	IV bolus of dextrose
Hypokalemia	Flat T waves and appearance of a U wave on the ECG	IV Magnesium infusion
Hyperkalemia	Peaked T waves and wide QRS complex on the ECG	Consider calcium chloride, sodium bicarbonate, and an insulin and glucose protocol
Hypothermia	Typically preceded by exposure to a cold environment	Gradual rewarming
Tension pneumothorax	Slow heart rate and narrow QRS complexes on the ECG; difficulty breathing	Thoracostomy or needle decompression
Tamponade - cardiac	Rapid heart rate and narrow QRS complexes on the ECG	Pericardiocentesis
Toxins	Typically will be seen as a prolonged QT interval on the ECG; may see neurological symptoms	Based on the specific toxin
Thrombosis (pulmonary embolus)	Rapid heart rate with narrow QRS complexes on the ECG	Surgical embolectomy or administration of fibrinolytics
Thrombosis (myocardial infarction)	ECG will be abnormal based on the location of the infarction	Dependent on extent and age of MI

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