Rebellion in EM 2019: All PEA is Not the Same via Tarlan Hedayati, MD

A 57-year-old man is watching his son’s baseball game when he suddenly collapses. Witnesses did not appreciate a pulse, so they started CPR. Unfortunately, an AED was not available. EMS was called and when they arrived within minutes the patient was found to be in vfib arrest and was defibrillated. When the patient arrived to the hospital, he was in PEA arrest. Ultrasound of the patient’s heart showed some coordinated cardiac activity. ACLS doesn’t really tell us how to proceed with cardiac activity but not enough to generate a pulse on the monitor.

Rebellion in EM 2019: All PEA is Not the Same via Tarlan Hedayati, MD


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True PEA = No cardiac activity observed with ultrasound.

Pseudo-PEA = Profound Shock (i.e. Minimal cardiac output unable to generate a MAP or a pulse)

FEEL = Focused Echocardiography Evaluation in Life Support:

  • German study looking at 4 EMS systems in urban and suburban areas looking at patients in cardiac arrest
  • The trucks all had EMS providers and a physician would do the echo
  • Results:
    • 51 patients were clinically diagnosed with PEA, US showed that 13 of those 51 patients had true PEA and 38 had pseduo PEA
    • US changed management in 78% of cases of all cases
    • Of the patients that were diagnosed with clinical asystole, 30% of them had cardiac activity on US
    • 55% of patients in pseudo-PEA went on to survive to admission

The Problem with Using Ultrasound at the Bedside

  • It delays CPR!
  • A study from Maryland looked at point of care ultrasound for patients in cardiac arrest. Filmed all the arrests and timed the use of POCUS. Found that when using US during arrest it would delayed pauses by 21 seconds, which is more than double the time we want for pauses in CPR

How can we Improve Delays?

  1. Start CPR / Continue CPR
  2. Rhythm check + record POCUS
  3. Count down 6 seconds
  4. Resume CPR
  5. Review images after resuming CPR

Cardiac Arrest Sonographic Assessment (CASA)

  • Algorithm put together from Highland in Oakland CA to assess cardiac activity/pathology during an arrest
    1. During first pass look for tamponade
    2. During second pass look for RV strain
    3. During the third pass assess for motion

PEA bottom line

  • All PEA is NOT the same.  Use ECHO to help differentiate, but minimize pauses

More Helpful Links About the Topic!

Post Transcribed By: Miguel Reyes, MD (Twitter: @miguel_reyesMD)

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)

Cite this article as: Salim Rezaie, "Rebellion in EM 2019: All PEA is Not the Same via Tarlan Hedayati, MD", REBEL EM blog, February 27, 2020. Available at:

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