#pulseless electrical activity

[cardioimages]

Pericardial tamponade, patient remained in persistent PEA after multiple rounds of CPR - Shared by Dr. Sam Ghali

[bedside-manner]

Nothing like finishing your shift with a little PEA.

[thewrightnurse]

Pulseless Electrical Activity (PEA):

PEA occurs when there is a heart rhythm on the strip (it's making a little bit of electricity), but the heart actually has NO mechanical activity (it's NOT pumping, and there's no output).  This is proof that you should ALWAYS check the patient, not just the monitors ( ;

START CPR (unless the patient has paperwork stating otherwise).

Causes of PEA:  Hypovolemia, hypoxia, acidosis, potassium imbalance, drug over-dose, cardiac tamponade, acute MI, PE, tension pneumothorax.

Treatment:  CPR, intubation, IV therapy with epinephrine, atropine, etc.  Correct the underlying cause!

[tymkrs]

CPR

So last night, during my shift, a patient coded.  I was in another patient's room hanging an antibiotic, and I heard the code alarm go off.  If you've ever heard this, it makes all of the hairs on your arm stand at attention, and your heart starts to race. 

I told my patient that I would be back in a bit, calmly walked out of his door to the hallway, and ran to the patient's room.  As I ran, I made sure someone had brought the code cart, and sure enough, it was headed into the door. 

You know how some people have that constant tanned look?  That's how the patient looked, but that wasn't the patient's normal color.  That was from lack of oxygen to anything. "Hey, are you okay?  Hey!  Wake up!  Hey!  Can you hear me?!"

A coworker was doing compressions, the charge nurse was getting the ambu bag on the patient's face and delivering oxygen.

The patient had been on an antiarrhythmic and while we had been running around to different patient rooms getting them pain medications and tucking them in or taking them to the bathroom, this person's heartrate had started to slow down more and more.  In a matter of seconds, the patient had gone from being in the 110s to pulseless electrical activity (PEA for short). 

So we got this hard board under the patient (so that compressions would be effective), and started counting.  By then, the code team and the primary surgical team had arrived and as calm as could be, the leader of the code team started directing people to different interventions.  In fact, unlike other chaotic codes, people were communicating, they were echoing back orders, and a progression was followed.

Three people were at the head of the patient, two at each side, a recorder, and what looked like 15 onlookers.  The three were responsible for intubating, suctioning (from gag reflex), and oxygenating.  My coworker and I were doing compressions, and two others were there to administer medications. 

My coworker was starting to fatigue and so I offered to jump in and continue the compressions.  Check for pulse. No pulse.  *clasp hands, place on sternal incision* Begin compressions.

First.  This patient was a lot softer than the dummies I had done CPR on.  I know that's a strange thing to think about, but it's true.  It almost seems easier, but then you start thinking about whether the compressions you're doing are good enough.  As you do compressions, you watch the depth of the chest depressions, and you hope to God that you've counted the proper number of compressions, and that you're doing them fast enough.  I kept thinking about the stupid song "Staying Alive" and went to that beat, but man, that is difficult. 

The leader was good though, she'd tell us when we needed to do them faster and would tell us when we were doing a good job.  A calm leader shouldn't be underestimated in such a situation.

But when you're doing CPR on another human being, you get tired a lot more easily for some reason, maybe because you know you're doing it for real, and that it actually matters whether the body is getting proper perfusion.  Someone saw that I needed to be relieved, and the charge nurse stepped in, got onto the bed, and began doing compressions.  "Pads on" "Epi" "Put gloves on" "We need to change the oxygen tank" "We need to transfer the patient to the ICU" "What happened" "Does anyone know this patient" *ABG values being read off* *arterial mapping scanner out**history of patient*

We kept doing compressions and watching the monitor for any sign of his own electrical activity.  The coworker and I would watch each other and nod when we needed to switch off.  We'd count for the other person so they didn't have to think about how many they had done.  30.  2.  30.  2.  The leader had her hand on the femoral constantly and was monitoring what everyone else was doing. 

"Good pulse, we have a good pulse.  Let's get a blood pressure and start preparing to take the patient back." *put cuff on patient* 80s/50s...130s/50s.  Good, let's book it.

*Gloves off* *Wash hands* *Note hands shaking*

"Good job Addie, I felt a good pulse while you were doing compressions"

"Thanks. Good job to you too. I hope the patient'll be alright."

An ICU nurse came out - the patient's doing alright though still intubated - was supposed to go home today actually.

My arms are still tensed up, and my hands still shake when I'm trying to focus.

The patient was soft.  And squishy.  And I hope the patient'll be alright.

@atdiy/@tymkrs