Case 4: Pulseless Electrical Activity
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Pretest
*Person Collapses (Adult, assume cardiac arrest)
*Check Responsiveness and Breathing - simultaneously (Shake and Shout or if trauma, Touch
  and Talk to pt)  "Are you awake?" - If unresponsive or if pt is not breathing or is agonally breathing, then*Call emergency response system (call 911 or if in a medical setting call a code blue or retrieve a
  defibrillator/AED if available) - the main rhythm associated with cardiac arrest in an adult is V.fib or
  Pulseless V. Tach and NEEDS to be shocked as soon as possible to survive.

Begin the Primary Survey
C-CIRCULATION (3 steps):
1.Check responsiveness and for breathing “shake and shout” or if trauma
         suspected “touch and talk” – look for chest rise – if no response or breathing
         or abnormal breathing go to next step
2.Call a Code Blue if in hospital or if out of hospital Call 9-1-1
3.a. Check Circulation- by palpating a carotid/femoral pulse (within 10
             seconds). If no definite pulse within 10 seconds then, begin chest
             compressions. If a definite pulse is felt, then give 1 breath every 5-6
             seconds. Recheck pulse every 2 minutes or 5 cycles. 
         b. Provide - CIRCULATION w/chest compressions and ventilations
             (30:2) for at least 100 compressions per minute, “hard and fast”, at
             least 2 inches deep with minimal interruptions. Allow for complete
             recoil of the chest after each compression.

A-AIRWAY:  Open the AIRWAY using head-tilt-chin lift, if trauma suspected, then use jaw thrust method. Even if trauma suspected and you are the only rescuer available, then open the airway using head-tilt-chin lift.

B- BREATHING: Assessment of this was done in step one - Provide BREATHING (2 breaths) allowing the chest to rise each time, give each breath over 1 second. Avoid excessive ventilations. If the breath does not go in, reposition the head by head-tilt-chin lift and attempt to deliver 2 breaths. Utilizing a bag-valve-mask (BVM) requires a good seal – E-C method, E with 3 fingers along jawbone and C with thumb and forefinger on the mask. Please note that this is best done with 2 rescuerers and not recommended for the single lone rescuer.

Helps Arrives

D=Defibrillation, Attach to a defibrillator-monitor or with paddles do a quick look for a shockable rhythm.  We are looking for V.fib or V.Tach to defibrilate. If any other rhythm shows up, then it is PEA (Pulseless Electrical Activity).

Begin Secondary Survey

C=Circulation, resume CPR beginning with chest compressions (30:2, at a rate of at least 100 bpm) for five cycles/2 minutes. Place IV, antecubital vein is the first choice and run IVFs if appropriate - Normal Saline or Lactated Ringers are the preferred choices or Intraosseous (IO) access.

A=Airway, consider securing the airway with an advanced airway, intubation. See Case 1 for an extensive explanation of advanced airways and intubation.   Capnography should be utilized with the advanced airway. PETCO2 (partial pressure of end tidal carbon dioxide) normal range is 35-40 mmHg. If < 10 mmHg, in arrest, then improve the quality of CPR.

B=Breathing, Confirm and secure the tube with an approved airway device and ventilate the patient with 100% oxygen (12-15 times per minute). 
Note:  Asynchronous chest compression may now be done with ETTube placement.

Epinephrine 1 mg IV q3-5 minutes
OR
Vasopressin 40 Units IV, one time dose or after 1st or 2nd dose of Epinephrine. (wait 10-20 minutes before starting epinephrine) 

Atropine has been eliminated from the PEA and Asystole Algorithm

Flush with 20mL NS or run IVFs to keep meds running into the vein and raise the arm.  After giving the drug, then resume CPR for 5 cycles/2 minutes beginning with chest compressions. 

D=Differential Diagnosis, Search for and treat reversible causes including but not limited to 5 Hs and 5 Ts:
Hypovolemia-give fluids and/or blood products (the #1 cause of PEA),
Hypoxia-give 100% ventilated oxygen,
Hypo/hyperkalemia(low or high K level)-give KCL boluses for low K+ level/-give NaHCO3 1mEq/kg IV q 10 minutes for high K+ level,
Hydrogen Ion (acidosis)-hyperventilate pt or give NaHCO3 depending upon lab values,
Hypothermia - remove wet/cold items, use warmed IVFs for hypothermia,
Thrombosis Pulmonary (PE)-thrombolytics or surgery to remove the blockage, Thrombosis Cardiac (MI)-thrombolytics or surgery to remove the blockage, Tension Pneumothorax-needle decompression,
Cardiac Tamponade-paracardial centesis,
Toxins - Used to be called Tablets (OD)-give NaHCO3 for certain antidepressants.

The following is a detailed explanation for dx and tx of the differential diagnois.

Hypovolemia can be evident from a trauma or from patient assessment.  It is the #1 cause of PEA.   Give IVFs Normal Saline or Lactated Ringers and even blood products if needed.  When the IV is placed, usually IVFs are hung and thereby treating the low volume problem.

Hypoxia is being treated in the A=Airway when the patient was intubated and ventilated with 100% oxygen.  The airway is ALWAYS the first priority.  It only takes a few minutes to cause a insult to the brain for lack of oxygen, so be vigilant with this assessment as an ongoing concern.

Hypokalemia seen with increased heart rate or arrythmias can be treated with Potassium boluses 10-20mEq over 1 hour (see your policy for total amount to be given as giving too rapid administration will stop a heart). 

Hyperkalemia seen with decreased heart rate and various blocks and arrythmias can be treated with Sodium Bicarbonate 1mEq/kg (class 1 intervention). It can be treated with D50W and IV Regular Insulin to get the K+ back into the cells or even Calcium Chloride. 

Hydrogen Ion (acidosis) is a little more complicated.  1st we would need a ABG (arterial blood gas) to determine respiratory or metabolic acidosis, but mainly we want to look at the PH (7.35-7.45 is generally the norm, again look at your lab policy).  If less than 7.2, then we need to rapidly correct this by possibly hyperventilating the patient or considering NaHCO3 (Sodium Bicarbonate).  The problem with hyperventilating is that it can hurt certain types of patients such as head-injuries by reducing ICP but at the same time constricting the blood vessels thereby reducing blood flow and the oxygen it carries.  The problem with Sodium Bicarbonate is that correcting the patient and making him or her alkalotic causes problems that are not as easily reversed.  We don't want to hypoventilate a patient to let their CO2 level increase.  So generally, we will treat this specific to the patient problem by looking at the ABGs, telling us the source respiratory or renal (metabolic) cause.

Hypothermia is treated by warming the patient and possibly running warmed IVFs.
Now we have classifications for Hypothermia:
1. Mild Hypothermia 34°C (93.2°F) - Passive rewarming will generally work for mild hypothermia - getting wet/cold items off and warm blankets and warm environment.
2. Moderate Hypothermia 30°C to 34°C (86°F to 93.2°F) - external rewarming will be needed
3. Severe Hypothermia 30C (86°F) - Active external warming techniques include forced air or other efficient surfacewarming devices.

Patients with severe hypothermia and cardiac arrest can be rewarmed most rapidly with cardiopulmonary bypass. Alternative effective core rewarming techniques include warm-water lavage of the thoracic cavity and extracorporeal blood warming with partial bypass.
Adjunctive core rewarming techniques include warmed IV or intraosseous (IO) fluids and warm humidified oxygen. Heat transfer with these measures is not rapid, and should be considered supplementary to active warming techniques.

Hypoglycemia has been eliminated in the new 2010 guidelines. There have been mixed studies showing the very tightly controlled blood sugars were not as beneficial as orginially thought. There is general consensus that the lowered blood sugars are helpful by reducing risk of infection and other complications, but increasing vigilance is needed to prevent hypoglycemic episodes that occur with increased insulin IV administration. Hypoglycemia may be deadly, and needs to be treated with IV dextrose.

Thrombosis, pulmonary can be seen by ventilating the patient well, good bilateral breath sounds; yet, poor saturations and even mottled skin color. What is happening is that the perfusion side of the V/Q (ventilation/perfusion) equation is being affected.  The oxygen is being delivered through ventilations, but the oxygen in the blood cannot carry it to the rest of the body because there is a blockage in the vessels of the lungs.  This can be corrected with either thrombolytics or through surgery to remove the blockage.  

Thrombosis, cardiac can be confirmed with a 12 lead ECG, seeing a Q wave with ST elevation and T wave inversion; however, a patient can have a non-Q wave MI. ST elevation STEMI is what we are looking for on the ECG or a nonSTEMI where clinically the patient presents with symptoms but does not show ST elevation on the 12 lead ECG. A patient with a cardiac history, or signs and symptoms of a "heart attack" like chest pain, "heavy" feeling on the chest, neck or jaw discomfort, nausea, diaphoresis, arm or shoulder discomfort before the code blue may give you an idea that an MI has occurred.  The fact that a patient is in V.fib or V.tach generally leads us to believe a "heart attack" has occurred. The ways to correct this is by thrombolytics, heart catherization, or heart surgery (CABG-coronary artery bypass graft), a reprofusion strategy. 

Tension pneumothorax is heard in a loss of breath sounds, generally on one lung field (both lungs could be affected).  While continually assessing the B=Breathing, this should be noticed if the patient suddenly has one sided chest rise or low oxygen saturations. Check this first by listening for breath sounds and checking E.T. tube placement.  To correct this take a large bore needle such as 14g needle and along the side where lung sounds are diminished find the 2nd-3rd anterior ribs at the mid-clavicular line and place the needle to hit the 2nd rib and go just underneath it into the 2nd ICS, and we should hear pop, then a release of air.  A chest tube will need to be placed, but until then, if available connect to a flutter valve.  A flutter valve can be made with a torn finger of a glove with a small hole poked in the finger tape the finger over the hub. The small hole will act as a flutter valve.  Also, IV tubing connected to the needle and placed in water will crudely act as a water seal until more appropriate equipment can be applied.

Cardiac Tamponade is a life-threatening condition caused by fluid under pressure around the heart. Fluid that collects in the pericardial sac (the tissue sac in which the heart lies) can develop enough pressure to prevent the heart from relaxing completely between beats. Usually, this fluid has accumulated rapidly, and the increase in pericardial pressure causes a sudden decrease in cardiac output.  Commonly seen symptoms require a live patient with the ability to complain of dyspnea, chest pain or of a heart beat and circulation as heard with muffled heart sounds and seen with Pulsus Paradoxus (inspiratory drop in blood pressure greater than 10mm Hg) and jugular venous distention (JVD)-to perform this, the patient needs to be sitting up ideally 45 degrees, in a code most patients will be flat and will have JVD, so trauma history, cardiac history, and events leading up to the code blue become very important.  To fix the problem, we need to withdraw the fluid with a needle and syringe.  Only experienced personnel should attempt this because of the risk of further damaging the heart or its vessels.  Procedure:  A small puncture is made just below and to the left of xiphoid process.  A long needle is positioned at 45 degrees abovethe body and 45 degrees to the right of midline.  Through the skin puncture, the needle is advanced (the 60 mL syringe attached should be aspirated the entire time) in the position towards head and towards the left scapula. Withdraw the syringe and aspirate unclotted blood from pericardial sac.  Note:  This blood will not clot and is one way to tell if your in the pericardial sac.  From a 12 lead ECG machine, attaching the lead V aligator clip to the needle as you insert.  This will help determine position and if any arrythmias occur.

Tablets (Drug Overdose) is another issue with multiple treatments depending upon the problem.  The treatment depends upon the drug taken.  For tricyclic antidepressants and for phenobarbitone overdoses, give Sodium Bicarbanate to alkalize the urine.  If pt has an established heart history look for drugs such as Digoxin to be the culprit and treat accordingly.  This is not an attempt to cover all drug possibilities.  This is too broad of an area to discuss all possible drug overdoses. The clinician will use their assesment skills for the patient and the environment to pick up on clues causing the problem.  Dialysis can also be used as a treatment in a critical situation as in Hyperkalemia to remove the unwanted substance quickly, but even then, some drugs cannot be removed by dialysis.  Many times clinicians treat the symptoms of the overdose until the cause can be determined or counteracted.
God Knows
God Knows