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Cardiology Corner - A Common Sense PEA Algorithm

Amal Mattu, MD FAAEM and Rob Orman, MD
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Nurses Edition Commentary

Mel Herbert, MD MBBS FAAEM, Lisa Chavez, RN, and Kathy Garvin, RN
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EM:RAP 2014 August - Summary 1 MB - PDF

When was the last time running through the H's and T's of the ACLS PEA algorithm actually helped you? If you can count the number of times on one finger or less, Amal Mattu has good news - There’s a better way!

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Donald Z., M.D. -

so if you have "real" pea you undoubtedly will be doing compressions so how do you advise timing the ultrasound practically speaking?

Amal M., M.D. -

I'm sure the u/s gurus might be able to give more specific advice, but I'd recommend just doing a really quick look during the pulse check. Do the best you can to minimize hands-off time.
I'm told by some of the u/s experts that they are good enough to see cardiac activity during the compressions....I'm not that good.

Gregory O. -

I was amazed by the agreement on not doing compressions. These patients as a whole have terrible outcomes. Seems like a hard position to defend from a medmal standpoint. I would not want to be in court staring at a giant poster of the ACLS algorithms. I try to agressively do all the other possible interventions that help, but I still do compressions. I am not aware of any studies that show that compressions are harmful.

Amal M., M.D. -

I hoped to convey that there's probably no harm in doing compressions. There's really not enough evidence one way or the other.
As for the agreement about withholding compressions, I think the point to be made is that if there's organized cardiac activity noted on U/S, the speakers are suggesting in this case that you'll get better improvement in perfusion with IVF and vasoactive drugs than with compressions. I'd take that a step further, though, and actually suggest that if your compressions (in a person with organized mechanical cardiac activity) are not properly timed with the patient's cardiac cycle, you might actually be impairing cardiac output. Not an issue with asystole, but with organized activity, if you compress during the patient's diastole, you will impair ventricular filling. And it's pretty much impossible to coordinate chest compressions with cardiac activity. There's no studies one way or the other on this and never will be so we'll never know.
Bottom line--there are reasons to say that withholding compressions in the scenario in favor of just going with IVF + pressors or inotropes is very reasonable.
In terms of the legal implications, the fact that there is no consensus and that here's a podcast with national figures saying they'd hold off on compressions demonstrates that there's no consensus on this issue, and that ACLS is not definitive. Discussions like this would provide good defense in legal cases.

Slayer of Dragons -

Worked a 65yo gentleman a few weeks ago that, 25mins before arrival, was standing in the living room talking to his family and then just hit the ground. Family had placed a nasal cannula and then waited for EMS (no compressions). EMS arrived in about 10mins. On arrival to the ER, he was in Vfib, compressions ongoing, inubated and had recieved epi x4. Shocked him immediately and gave amiodarone, bicarb and calcium. At 2min pulse check, there was narrow organized rhythm (NOR) on the monitor, no palpable pulse and no activity on USN. Continued CPR while brainstorming, but at every pulse check, there still was a NOR but no activity on USN. Pulse ox was hanging around 85% and BP was 100-110's. Cardiac window was unremarkable for intra- or peri-cardiac abnormalities, lungs were clear, IVC appear filled and no notable fluid in the abdominal windows. This left just a few possibilities that were either chemistry-based or mechanically wrong. The rhythm and the cardiac USN never changed, and after 25mins, it was decided to call the code. Before ending the code and since there continued to be a NOR on the monitor, the ultrasound was left on the 4 chamber view for 1min. There was no quivering, chamber enlargement, effusion, or occasional contraction.
I listened to the podcast, read the paper and based on those, a massive PE was the likely culprit. This is what we finally assumed at the time BUT MOST IMPORTANTLY, we also took much longer to finally conclude this (50mins of resuscitation) than the 30sec it took after reading the paper and looking a the algorithm. Would choosing to go down the PE route early and giving tpa have changed the outcome? I don't know, but it would have made it much easier to call the code and walk out of the room while the monitor was still showing activity. Of note, we held off on tpa because the wife gave a history of a previously repaired leaking AAA and there was also blood being suctioned out of the ET tube during the code.

Diana F., M.D. -

I am late to the discussion but a case I had yesterday made me re-listen to this segment. I had an 81 year old woman who came in shocky and profoundly hypothermic who rapidly lost pulses during initial resuscitation. US had shown organized cardiac activity but very decreased contractility. Compressions were started for PEA. I think this lady would have died no matter what we did, but I'm certain that breaking her ribs and continuing CPR until there was blood coming out the ET tube didn't help. In retrospect, I wish I'd had the courage to stick to medical management without CPR in this frail elderly lady- that would probably have been her only chance. This segment made a lot of sense to me. I don't see how pushing on a heart that is trying to beat but isn't strong enough to generate a palpable pulse (a very subjective measure btw!) is going to help. I will do this differently next time. Thanks for the interesting discussion.

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Episode 155 Full episode audio for MD edition 275:00 min - 131 MB - M4AEM:RAP 2014 août Résumé en Francais Français 65:33 min - 60 MB - MP3EM:RAP 2014 August Aussie Edition Australian 73:57 min - 102 MB - MP3EM:RAP 2014 August Canadian Edition Canadian 30:52 min - 43 MB - MP3EM:RAP 2014 Augusto Resumen Español Español 83:27 min - 77 MB - MP3EM:RAP 2014 August MP3 359 MB - ZIPEM:RAP 2014 August - Summary 1 MB - PDFEM:RAP 2014 August Board Review Questions 379 KB - PDFEM:RAP 2014 August Board Review Answers 421 KB - PDF

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