Understanding the algorithm
General Approach To PEA
PEA is pulseless electrical activity: the monitor shows organized electrical activity, but when you check a central pulse, there is none. The rhythm may be fast or slow, narrow or wide. Distinguish PEA from VF and pulseless VT, which follow the shockable-rhythm pathway.
Think about the code in two parallel tracks. One part of your brain keeps the resuscitation moving; the other works out why the patient arrested and what you can reverse.
Run The Resuscitation
- Keep high-quality CPR, oxygenation and ventilation, IV/IO access, monitoring, and epinephrine running as a coordinated team effort.
Find And Reverse The Cause
- Keep asking: What is causing this arrest, and can I reverse it? Use the history, examination, available tests, and focused ultrasound to direct treatment.
- The reversible causes are traditionally organized as the Hs and Ts. During a code, it is often easier to work through practical groups that connect a suspected cause to something you can do immediately.
Continuous Treatment — CPR + Epinephrine
- This part of the code continues while the team works through the reversible causes.
- Continue high-quality CPR, oxygenation and ventilation, and IV/IO access. Give epinephrine 1 mg IV/IO as soon as feasible, then repeat every 3–5 minutes.
- Recheck the rhythm every 2 minutes. If the rhythm is organized, briefly check for a pulse. If it becomes VF or pulseless VT, move to the defibrillation pathway.
- A focused ultrasound view can be obtained during the planned pulse check, but do not prolong the pause in CPR.
- With an advanced airway, follow ETCO₂. Low values should prompt reassessment of CPR quality; a sudden sustained rise suggests return of spontaneous circulation (ROSC). A practical goal is ≥10 mmHg, ideally ≥20 mmHg. Interpret the value in context and do not use it alone to end resuscitation.
01 Fix Rapidly Reversible Problems
- The clinical context should immediately change what you do. Trauma, GI bleeding, vaginal bleeding, recent surgery, or another obvious source of volume loss makes hypovolemia an actionable concern.
Hypoxia
- Give oxygen and ventilate. Confirm the airway and tube position if the patient is intubated.
Hypovolemia
- Give volume. If hemorrhage is suspected, move quickly toward blood products and hemorrhage control rather than relying on crystalloid.
Hypothermia
- Begin active rewarming.
- If this is traumatic arrest, move into the Trauma: Cardiac Arrest algorithm.
02 Chemical Resuscitation
- Check glucose and electrolytes when possible. Let the history, ECG, and clinical setting guide cause-specific treatment while CPR continues.
Hyperkalemia
- Think especially about renal failure, dialysis, or a dialysis access/fistula. In suspected hyperkalemic arrest, consider IV calcium and potassium-shifting therapy. The 2025 AHA guidelines note that the effectiveness of calcium, bicarbonate, and insulin/glucose during hyperkalemic cardiac arrest is not well established.
Sodium-Channel Blocker Toxicity / TCA Overdose
- Give sodium bicarbonate for life-threatening cardiotoxicity.
Hypoglycemia
- Give dextrose when glucose is low.
- Calcium, bicarbonate, and dextrose are not routine drugs for every PEA arrest. Use them promptly when the suspected cause fits the treatment.
03 Look For Mechanical Causes
- Use POCUS during planned pauses in CPR without extending the pause. A focused view should help answer a specific clinical question.
Tension Pneumothorax
Lung ultrasound: Assess lung sliding and other signs of pneumothorax. Absent sliding alone does not establish the diagnosis. If tension pneumothorax is clinically suspected, perform immediate decompression.- Cardiac ultrasound: Look for:
Cardiac Tamponade
Pericardial effusion with signs of tamponade.- RV dilation in the clinical context of suspected pulmonary embolism.
- Findings suggesting severe hypovolemia.
- Cardiac motion versus standstill.
- RV dilation alone does not diagnose PE during arrest. Interpret it alongside the history and other findings. Trauma plus tamponade may require resuscitative thoracotomy rather than prolonged diagnostic workup.
04 Thrombolysis And Coronary Reperfusion
Pulmonary Embolism
- Was there sudden dyspnea, syncope, unilateral leg swelling, recent immobilization, or RV dilation? If PE is strongly suspected as the cause of arrest, consider systemic thrombolysis.
Myocardial Infarction
- Was there preceding chest pain or evidence of acute coronary occlusion? If ROSC occurs, assess promptly for the coronary reperfusion pathway when clinically indicated.
Keep both tracks moving. CPR and epinephrine support perfusion while you identify and reverse the cause of the arrest.
Cases
References
View Full References
- PEA · Pulseless Electrical Activity. The Chief Complaint. Updated algorithm, 2026.
- 2025 AHA Adult Advanced Life Support.
- 2025 AHA Special Circumstances of Resuscitation.
- 2025 ERC Adult Advanced Life Support. POCUS during cardiac arrest.
- European Respiratory Society statement on thoracic ultrasound. Interpreting lung ultrasound findings.