PEA arrest: Chest compressions aren’t enough Susan P. Torrey, MD, FAAEM, FACEP Associate Professor of Emergency Medicine UMass Medical School – Baystate Medical Center

I have nothing to declare, but… www.TorreyEKG.com

150 patients survived PEA arrest without severe disability at 1 year Outcomes following out-of-hospital cardiac arrest with asystole or PEA (Australia) Andrew E Resuscitation 85:1633-1639, 2014 38,378 non-shockable OHCA / 10 years – 12% PEA Survival to hospital discharge – 6% No trend toward improved survival over 10 years Follow-up at 1 year Death, vegetative state or severe disability – 45% 150 patients survived PEA arrest without severe disability at 1 year

PEA…what next?

5H’s and 5T’s Hypovolemia Hypoxia Hyperkalemia Hypothermia H+ ions (acidosis) Tension pneumothorax Tamponade Toxins Thrombosis (PE) Thrombosis (MI)

Pulseless Electrical Activity SCA -- >300,000 cases/year in US Accounts for 50% of cardiovascular deaths PEA/asystole #’s have NOT changed in 30 years Reduction in VT/VF during same interval Subsets Non-cardiac (5H’s & 5T’s) Cardiac Primary – initial rhythm Secondary – following shock of VT/VF

Factors associated with out-of-hospital cardiac arrest with PEA: population-based study Ko DT Am Heart J 177:129-137, 2016 Toronto, 2005-2010, nontraumatic cardiac arrest 9,882 patients 24% PEA 26% shockable 50% asystole Patients with PEA vs shockable rhythm Older (age 72 vs 65) More likely female (41% vs 22%) More comorbid diagnoses More recent healthcare (ED 1 month 20% vs 10%)

ECG patterns in early PEA Bergum D, et al. Resuscitation 104:34, 2016

RUSH exam Rapid Ultrasound in Shock Cardiac Tamponade LV size and fx - RV size ?PE IVC & Lungs IVC collapsibility Lungs ?pneumo Abd ?free fluid Aorta Legs ?DVT

PEA in PE thrombolysis Sharifi M, et al. Am J Emerg Med 34:1963, 2016 23 pts with PEA receiving CPR due to massive PE Rx 50mg tPA IV push in 1 minute during CPR Initiation of CPR to tPA was 6.5 ± 2.1 min (all IHCA) 22/23 pts - ROSC in 2 – 15 min after tPA At 22 ± 3 months – 20 pts alive (87%) Survivors all returned to pre-event functional capacity Low-dose systemic tPA at 50mg is very safe No major bleeding Safe to administer as bolus over 1 minute

Causes of in-hospital cardiac arrest Bergum D, et al Causes of in-hospital cardiac arrest Bergum D, et al. Resuscitation 87:63-68, 2015. 302 episodes over 5 years at 1000-bed hospital Causes of arrest Cardiac causes – 60% Hypovolemia – 8% Hypoxia – 20% Tamponade – 6% PE – 5% Survived to hospital discharge – 25% VT/VF – 53% PEA – 13% Asystole – 17%

Initial rhythm in PEA (IHCA) Bergum D, et al. Resuscitation 87:63, 2015. Total n = 302

If we are going to improve survival in PEA arrest… EMS has to return to “scoop and run” Excellent CPR and IV fluid resuscitation Beyond ACLS – think hyperkalemia, hypoxia Early diagnostic ultrasound and interventions

CPR isn’t enough, but it is important Improved blood flow during CPR results in  survival Mechanical CPR devices – consistency Monitoring cardiac function during CPR Echocardiographiy for End-tidal CO2 > 16mmHg – predicts survival Pharmacological interventions Epinephrine vs. vasopressin Atropine no longer recommended SOS-KANTO study (2011) -  30-day survival

If we are going to improve survival in PEA arrest… EMS has to return to “scoop and run” Excellent CPR and IV fluid resuscitation Beyond ACLS – think hyperkalemia, hypoxia Early diagnostic ultrasound and interventions If all else fails  ECMO in certain situations

VA-ECMO Cannulation Complications During CPR For cardiogenic shock Shock after ROSC / CPR Complications CVA Acute renal failure Major bleeding

Extracorporeal CPR for IHCA Singal RK, et al. Can J Card 33:51, 2017 ELSO (Extracorporeal Life Support Org) 2379 cases E-CPR with 30% survival to discharge Initiation ECMO < 30 minutes V tach/v fib >> PEA Age < 65 years Bridging to: CABG, myocardial recovery, insertion LVAD, transplant PE, cardiotoxic OD, hypothermia

- - + E-CPR + Medical Management Indications: CA refractory to ACLS of suspected reversible origin: Cardiac, PE, toxins, hypothermia Contraindications: - Asystole as initial rhythm - ETCO2 < 13 - Lactate > 13 - Prior poor prognosis - Unavailability of team - + Age < 65 Witnessed CA CPR <40 min Reversible cause E-CPR - + Medical Management Singal R, at al. Can J Card 2017

Summary PEA is a spectrum of disease CPR must be very good Attempt IV fluid resuscitation Early identification of reversible causes Decrease pre-hospital times ± rhythm analysis Ultrasound evaluation – RUSH ECMO for a select group