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