ACLS - Pseudo-PEA

Pseudo-PEA: a state of profound shock leading to the inability of manual pulse detection despite the existence of organized cardiac electrical and mechanical activities. Distinct from true electro-mechanical dissociation

In a multi-centered study, only fewer than 50% of “PEA” patients had no cardiac activities observable with ultrasound (Source). Some available reports show that pseudo-PEA patients typically have more favorable outcomes if their underlying pathophysiology identified and sufficiently treated in a timely manner.

Pseudo-PEA has a better prognosis than true PEA -- therefore it is important to detect and treat in ALL presumed PEA arrest. - Prosen et al, 2012: 94% of patients received ROSC and 50% had good neurological outcomes - Flato et al, 2015: 70.4% ROSC for those in pseudo-EMD, 20.0% for those in EMD, and 23.5% for those in asystole

Detection of Pseudo-PEA

Pseudo-PEA can be detected in the absence of a palpable pulse by: - arterial line placement during cardiac arrest (identified by the presence of a blood pressure) - high ETCO2 readings in intubated patients - echocardiography or Doppler ultrasound demonstrating cardiac pulsatility

Management of Pseudo-PEA

  1. Avoid CPR
  2. Treat as profound shock
    1. Fluids
    2. Vasopressors (push dose, early infusion)
    3. POCUS examination to rule out PTX, tamponade, RV strain, assess IVC filling, etc.
    4. Consider labs to rule out electrolyte disturbances and acidosis which are treatable (i.e. go through the H's and T's)
    5. Intubate and line these patients. Monitor ETCO2 and arterial pressure.

References

  1. PEA Arrest, PseudoPEA & PREM | Emergency Medicine Cases
  2. Pseudo-PEA: An easily overlooked player in cardiac arrest - Resuscitation
  3. REBEL Cast Ep 54: What the Heck is Pseudo-PEA? - REBEL EM - Emergency Medicine Blog