A thorough yet quick history should be reviewed while paying special attention to the following:

• Risk factors for myocardial infarction or pulmonary embolism
• Any trauma
• Severe fluid loss
• Exposure to low temperatures
• Risk of metabolic derangements

Physical findings, as the name indicates, include an absence of palpable pulses is the foremost finding.

Depending upon the cause, one may see the following:

• Tracheal deviation
• Decreased skin turgor
• Traumatic chest
• Cool extremities
• Tachycardia
• Cyanosis[15]

Investigations should include an electrocardiogram (EKG), arterial blood gas analysis, serum electrolytes, core body temperature, chest radiograph, and echocardiogram.[16]

The first step in managing pulseless electrical activity is to begin chest compressions according to the advanced cardiac life support (ACLS) protocol followed by administrating epinephrine every 3 to 5 minutes, while simultaneously looking for any reversible causes. Once a diagnosis is made, begin immediate, specific management, i.e., decompression of pneumothorax, pericardial drain for tamponade, fluids infusion for hypovolemia, correction of body temperature for hypothermia, administration of thrombolytics for myocardial infarction or pulmonary embolism. An arterial blood gas and serum electrolytes should be obtained during the resuscitation process.

Epinephrine should be administered in 1 mg doses intravenously (IV)/intraosseously (IO) every 3 to 5 minutes during pulseless electrical activity arrest. Each dose should be followed by 20 ml of flush and elevating the arm for 10 to 20 seconds for better perfusion. Higher doses of epinephrine have not shown to improve survival or neurologic outcomes in most patients. Selected patients, like those with beta-blockers or calcium channel blockers overdose, may benefit from higher-dose epinephrine. It can also be given via an endotracheal tube after mixing 2 mg in 10 ml of normal saline.[17]

If the detected rhythm is bradycardia that is associated with hypotension, then atropine (1 mg IV every 3-5 min, up to three doses) should be administered. This is considered the optimal dose, beyond which no further benefit will occur. Note that atropine may cause pupillary dilation; therefore, this sign cannot be used to assess neurologic function.[18]

Sodium bicarbonate may be used only in patients with severe, systemic acidosis, hyperkalemia, or tricarboxylic acid overdose. The dose is 1 mEq/kg. Avoid routine administration of sodium bicarbonate as it worsens intracellular and intracerebral acidosis without affecting mortality. 

Pericardial drainage and emergent surgery may be lifesaving in appropriate patients with pulseless electrical activity. In a patient with a refractory case and chest trauma, a thoracotomy may be performed. Near pulseless electrical activity or a very low-output state may also be managed with the circulatory assistance (e.g., intra-aortic balloon pump, extracorporeal membrane oxygenation, cardiopulmonary bypass, and ventricular assist device).

The chances of a successful outcome depend on a very coordinated resuscitation process. There should be a specific person responsible for specific steps and a good team leader.

• Accelerated idioventricular rhythm
• Acidosis
• Cardiac tamponade
• Drug overdose
• Hypokalemia
• Hypothermia
• Hypovolemia
• Hypoxemia
• Myocardial ischemia
• Pulmonary embolism
• Syncope
• Tension pneumothorax
• Ventricular fibrillation[19]

Patients who have sudden cardiac arrest due to pulseless electrical activity have a poor outcome. In one study of 150 such patients, 23% were resuscitated and survived to hospital admission; only 11% survived until hospital discharge.

Unfortunately, despite optimal cardiopulmonary resuscitation, pulseless electrical activity still carries a high mortality rate.[20][21]

The following complications are likely to be seen in pulseless electrical activity:

• Rib fracture due to chest compression
• Ischemia of extremities due to poor perfusion
• Anoxic injury to the brain[22]

The following consultations may be requested to detect and manage the underlying causes of pulseless electrical activity:

• Usually, patients are sent to the intensive care unit (ICU) and managed by the intensivist provider.
• Vascular surgery consult if a large pulmonary embolus is detected.
• Toxicologist for suspected poisoning.
• Cardiothoracic surgery consult for cardiac tamponade.
• Cardiologist for myocardial infarction.

Most of the cardiac arrests are preceded by changes in the vital signs, including tachycardia, hypoxia, and tachypnea. Health care professionals should pay attention to such changes and look into the causes and treat them to prevent a potential cardiac arrest due to PEA.

• Pulseless electrical activity is a significant cause of mortality, especially in hospitalized, elderly patients.
• Immediate evaluation to look for the cause is warranted.
• Good quality cardiopulmonary resuscitation is the first step after the activation of the emergency response system.
• Epinephrine should be used in conjunction with cardiopulmonary resuscitation.
• The foremost priority is the hemodynamic stability of the patient.
• A six-person, high-performance cardiac arrest team, is best to manage patients with PEA.

All healthcare workers, especially emergency department physicians, nurses, urgent care workers, internists, intensivists, and trauma specialists, must be certified in ALCS. While there are many causes of cardiac arrest, one needs to be aware of pulseless electrical activity, which carries a high mortality rate.

The first step in managing pulseless electrical activity is to start chest compressions according to the ACLS protocol along with using epinephrine, while simultaneously looking for any reversible causes. Once a diagnosis is made, begin immediate management, i.e., decompression of pneumothorax, pericardial drain for tamponade, fluids infusion, correction of body temperature, administration of thrombolytics, or surgical embolectomy for pulmonary embolus. A successful outcome very much depends on the combined efforts of an interprofessional team.