![]() ![]() ![]() During this time applying ETCO2 and/or arterial line placement is recommended to assure good compressions and assessing for a possible perfusing cardiac activity with ETCO2 >40 and/or end-diastolic pressure >40mmHG.Īt the first pulse check, they recommend a quick (<5-10sec) POCUS echo to assess for cardiac activity. If no vessel pulsation is identified then they recommend initiating CPR, IV access, and 1mg of epinephrine. This is thought to be more sensitive than using the palpation method of pulse check. Essentially this is placing a linear probe over the carotid or femoral arteries to look for vessel pulsation. In their algorithm, they recommend a POCUS pulse check (8). Helman, Simard and Weingart created a tremendous algorithm that helped quickly diagnose and more appropriately treat PREM and PRES (7). In a podcast from emergency medicine case, Dr. Thromboembolism – thrombolysis (proven or suspected pulmonary embolus) +/- surgical embolectomy.Tamponade – pericardiocentesis, open chest.Tension pneumothorax – decompress (needle or finger thoracostomy prior to the intercostal catheter).Toxicity – stop absorption, increase elimination, an antidote to a specific drug.Hyperthermia – cool, dantrolene for malignant hyperthermia.Metabolic disorders – Mg2+ if low, Ca2+ if low, consider bicarbonate for acidemia (e.g.Hyperkalemia – treat cause, Ca2+ gluconate 10mL 10%, insulin-dextrose, salbutamol, NaHCO3.Hypoxia – intubation, and ventilation (FiO2 1.0).Hypovolemia – fluid, blood products, stop bleeding, clamp vessels.In both PREM and PRES, the H’s and T’s should be investigated as potential causes and with prompt treatment (5). In the case of PREM, it would be better managed as a profound shock with vasopressors to support and investigate the causes of shock. Additionally, too much epinephrine may also be detrimental. Doing chest compressions, in this case, has shown to be deleterious in animal models as it may interfere with cardiac filling. Here, the early recognition of cardiac activity with POCUS echo is crucial. However, in the case of PREM, the heart is generating rhythm and cardiac activity, but the pulse may be too weak to appreciate due to profound shock. PRES is true cardiac arrest, having no cardiac activity found on POCUS echo during the resuscitation, CPR and epinephrine make sense by compressing on the heart to generate an artificial perfusing pressure and using epinephrine to increase vascular tone, cardiac rate, contractility, and automaticity. PREM on the other hand has a much more favorable prognosis with some papers showing as high as 70-94% rate of ROSC and about 50% had a good neurological outcome (3,4).īeyond the prognostic difference in PRES and PREM, the management of the two entities is really quite different. The prognosis of PRES is really quite dismal at 5.9% survival to discharge (2). The heterogeneity of PRES and PREM makes this algorithm inappropriate and antiquated. ![]() In reality, these two entities are really quite different from each other, yet in ACLS the algorithm it is more of a “one size fits all.” The ACLS protocol for PEA includes the ABCs, CPR, Epi 1 mg every 3-5 minutes IVP, and consideration of the reversible causes by reviewing the H’s and T’s with no mention of looking for a cardiac activity with POCUS echo. PREM (Pulseless with a Rhythm and Echocardiographic Motion).PRES (Pulseless with a Rhythm and Echocardiographic Standstill).Terms coined by Scott Weingart may be better descriptors of this entity (1): The important first point to recognize the differences between PEA and Pseudo-PEA is the echocardiographic findings. Pseudo-PEA is an organized electrical cardiac rhythm and it has cardiac muscle activity (found on POCUS echo) however, there may not be a palpable pulse due to profound shock.True PEA, once known as electro-mechanical dissociation is the presents of an organized electrical cardiac rhythm without cardiac muscle activity (cardiac standstill).In this post, we’ll talk about PEA, Pseudo PEA, and why we should look beyond the ACLS algorithm. The HIMAP version of the Rush Exam protocol is extremely helpful in identifying causes of shock and should be utilized in these cases (6).PEA and PseudoPEA: A Proposed new Algorithm We do have a very powerful tool at our disposal that can help quickly identify possible causes of profound shock as well as PREM and PRES, ultrasound. ![]()
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