Pediatric Advance Life Support: Pulseless Electrical Activity (PEA)

Vasoconstrictors

Epinephrine 0.01mg/kg (0.1ml/kg of a 1:10,100 solution) IV or IO

Epinephrine 0.1mg/kg (0.1ml of a 1:1000 solution) via ET tube

May repeat dose every 3-5 minutes

Note:  Epinephrine increases the heart rate and myocardial contractility more effectively than atropine through its alpha- and beta-adrenergic receptor stimulation. Its direct chronotropic effects (beta-agonist) and vasoconstrictor effects (alpha-agonist) increase mean arterial blood pressure, coronary perfusion pressure, and myocardial oxygen delivery. While epinephrine does increase myocardial oxygen consumption, it poses no significant risk of causing myocardial infarction in children as it does in adults.

Evaluate Reversible Causes

·         Hypoxia

·         Hypovolemia

·         Hyper/hypokalemia

·         Hypothermia

·         Tension pneumothorax

·         Tamponade

·         Thromboembolism

·         Tables/toxins

·         Trauma

Note:  Management of PEA is exactly the same as for asystole. Interventions for specific causes of PEA may lead to successful resuscitation. Appropriate measures may include a rapid fluid bolus for potential hypovolemia (20 mL/kg normal saline or lactated Ringer’s administered IV or IO), needle decompression for suspected tension pneumothorax, ventilation and sodium bicarbonate for acidosis, or pericardiocentesis for cardiac tamponade as regional protocols permit.

Evaluate Reversible Causes

·         Hypoxia- use DOPE mnemonic

·         Hypovolemia- 20ml/kg fluid bolus

·         Hyper/hypokalemia- correct imbalance

·         Hypothermia- consider rewarming techniques

Note:  DOPE mnemonic- D: displacement of tube, 0: obstruction of tracheal tube, P: pneumothorax, E: Equipment failure

Management of PEA is exactly the same as for asystole. Interventions for specific causes of PEA may lead to successful resuscitation. Appropriate measures may include a rapid fluid bolus for potential hypovolemia (20 mL/kg normal saline or lactated Ringer’s administered IV or IO), needle decompression for suspected tension pneumothorax, ventilation and sodium bicarbonate for acidosis, or pericardiocentesis for cardiac tamponade as regional protocols permit.

Evaluate Reversible Causes

·         Tension pneumothorax- needle decompression

·         Tamponade: pericardiocentesis

·         Tables/toxins: tx based on specific toxin

·         Thromboembolism: rare and difficult to treat

Note:  In tension pneumothorax, PEA results when air trapped within 1 side of the chest pushes the mediastinum toward the opposite side. If this shift is extreme, venous blood return to the heart is occluded by kinks in the great vessels above and below the mediastinum. The heart continues to contract, giving rise to normal electrical activity on cardiac monitoring, but no blood is entering the heart, so there is no palpable pulse.

In cardiac tamponade, PEA results when blood or other fluid fills the pericardial sac that surrounds the heart, preventing it from pumping normally and markedly decreasing cardiac output. When the ventricles contract during systole, the pressure between the pericardium and myocardium decreases and additional fluid enters the sac. When the ventricles relax during diastole, pressure from the fluid in the pericardial space prevents them from returning to their normal volume. This presents classically with hypotension, muffled heart sounds, and distended neck veins (Beck’s Triad); the latter two findings may be difficult to discern in infants.

Post-resuscitation

·         Maintain normal ventilation

·         Monitor temperature

·         Manage post-ischemic myocardial dysfunction

·         Maintain normal glucose

Ethical concerns

·         Family presence during resuscitation

·         Designated staff member should be available to support and remain with family during resuscitation

·         Positive psychological effects            

·         Planning, staff acceptance

Sources

PALS Provider Manual. American Heart Association 7272 Greenville Ave. Dallas, Tx 75231

Kleinman ME, Chameides L, Schexnayder SM, Samson RA, Hazinski MF, Atkins DL, Berg MD, de Caen AR, Fink EL, Freid EB, Hickey RW, Marino BS, Nadkarni VM, Proctor LT, Qureshi FA, Sartorelli K, Topjian A, van der Jagt EW, Zaritsky AL. Part 14: pediatric advanced life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(suppl 3):S876–S908