Content uploaded by Matthew Mannion
Author content
All content in this area was uploaded by Matthew Mannion on Jul 12, 2021
Content may be subject to copyright.
UC Irvine
Journal of Education and Teaching in Emergency Medicine
Title
Pulseless Electrical Activity Cardiac Arrest
Permalink
https://escholarship.org/uc/item/2p29v1f4
Journal
Journal of Education and Teaching in Emergency Medicine, 5(1)
ISSN
2474-1949
Authors
Sembroski, Erik
McDowell, Christopher
Mannion, Matthew
Publication Date
2020
License
https://creativecommons.org/licenses/by/4.0/ 4.0
Peer reviewed
eScholarship.org Powered by the California Digital Library
University of California
SIMULATION
1
Pulseless Electrical Activity Cardiac Arrest
Erik Sembroski, MD*, Christopher M McDowell, MD^ and Matthew M Mannion,
BA^
*University of Missouri—Kansas City School of Medicine, Department of Internal Medicine, Kansas City, MO
^Southern Illinois University School of Medicine, Department of Emergency Medicine, Springfield, IL
Correspondence should be addressed to Erik Sembroski, MD at sembroske@gmail.com
Submitted: July 2, 2019; Accepted: October 21, 2019; Electronically Published: January 15, 2020; https://doi.org/10.21980/J8Z055
Copyright: © 2020 Sembroski, et al. This is an open access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) License.
See: http://creativecommons.org/licenses/by/4.0/
Empty Line Calibri Size 12
Empty Line Calibri Size 12
ABSTRACT:
Audience: This simulation-based scenario is appropriate for senior level emergency medicine residents.
Introduction: Pulseless electrical activity (PEA) accounts for up to 25% of sudden cardiac arrest;1 therefore
the ability to recognize and care for this condition is an essential skill of emergency medicine physicians.
Management of PEA arrest in the emergency department centers on Advanced Cardiac Life Support (ACLS)
algorithms and the identification and treatment of potentially reversible causes. Massive pulmonary
embolism (PE) is one of several causes of PEA cardiac arrest.2 However, diagnosis by CT-angiographic or
nuclear imaging may not be obtainable in the hemodynamically unstable patient, requiring physicians to have
a high index of suspicion. Systemic thrombolytic therapy is indicated in cardiac arrest due to known or
presumed massive pulmonary embolism.3,4,5
Educational Objectives: After competing this simulation-based session, the learner will be able to:
1. Identify PEA arrest
2. Review the ACLS commonly recognized PEA arrest etiologies via the H &T mnemonic
3. Review and discuss the risks and benefits of tissue plasminogen activator (tPA) for massive PE
Educational Methods: This is a high-fidelity simulation that allows learners to evaluate and treat a PEA arrest
secondary to massive PE in a safe environment. The learners will demonstrate their ability to recognize a PEA
arrest, sort through possible etiologies, and demonstrate treatment of a massive PE with tPA. Debriefing will
focus on diagnosis and management of the PEA arrest.
Research Methods: This case was piloted with 12 PGY-2 and PGY-3 residents. Group and individual debriefing
occurred post-case.
Results: Post-simulation feedback from the faculty suggested two potential issues. First was fidelity, which
we increased by using our ultrasound simulator. Second, the elevated presenting glucose with lactic acidosis
could be a poor cue, leading some towards diabetic ketoacidosis (DKA).
SIMULATION
2
Discussion: Learners felt more confident about running a PEA arrest. The simulation improved resident
awareness of the value of point of care ultrasound (POCUS) in cardiac arrest. It also clarified the dosing of
tPA in massive PE. Faculty felt simulating the actual US without breaking simulation would be more
challenging without our US simulator. Although there was concern about results pointing towards possible
DKA, this did not occur in any of the pilot simulations. The presenting glucose was reduced to make this less
likely in future simulations.
Topics: Pulseless electrical activity (PEA), syncope, cardiac arrest, Hs and Ts from ACLS PEA instruction, tPA
for massive PE, critical care medicine, simulation.
USER GUIDE
eturn: Calibri Size 10
Sembroski E, et al. Pulseless Electrical Activity Cardiac Arrest. JETem 2020. 5(1):S1-25.
https://doi.org/10.21980/J8Z055
3
Linked objectives and methods:
By completing this simulation, learners will take a brief history
and physical before the patient arrests. After intubation, the
patient will arrest and cardiopulmonary resuscitation (CPR) will
be initiated. The learner will identify PEA as the rhythm
(objective 1) and continue the resuscitation while divulging the
possible etiologies via the H&Ts mnemonic (objective 2). Once
PE is recognized as a likely cause, the learner with discuss the
pros & cons of tPA administration or be prompted to do so.
Although learners are familiar with PE, most learners have not
all seen cardiac arrest secondary to massive PE. Simulation
develops comfort with diagnostic uncertainty and the
administration of tPA without confirmatory imaging findings.
This case forces them to process the tPA administration risk and
benefits in a safe environment (objective 3). Debriefing will
ensure that any potential misconceptions or knowledge gaps
are addressed.
Recommended pre-reading for instructor:
• DePalo VA, Kharnaf AE. Venous Thromboembolism
(VTE) Treatment & Management. In: Medscape.
Panchbhavi VK, ed.
https://emedicine.medscape.com/article/1267714-
treatment#d10. Published June 12, 2019. Accessed July
2, 2019.
• Kline JA. Pulmonary embolism and deep vein
thrombosis. In: Walls RM, Hockberger RS, Gausche-Hill
M, et al. Rosen’s Emergency Medicine: Concepts and
Clinical Practice. 9th ed. Philadelphia, PA: Elsevier;
2018:1051-1066.
• Nickson C. Thrombolysis for submassive pulmonary
embolus. Life in the Fast Lane.
https://litfl.com/thrombolysis-for-submassive-
pulmonary-embolus/ Updated June 9, 2019. Accessed
July 2, 2019.
Results and tips for successful implementation:
This case is best implemented with a team comprised of the
learner/upper level resident, pharmacist, nurse, paramedic and
family member. We recommend inviting your ED nurses,
pharmacists or medics to participate. Faculty or other residents
can act as family or embedded participants if staff is not
available. The case was initially completed by 12 PGY-2 and
PGY-3 residents. Verbal debriefing evaluating the simulation
efficacy showed that learners became more comfortable
initiating tPA without confirmatory imaging after completing
this case. After the initial pilot, laboratory data (eg, venous
blood gas, glucose) was amended to prevent exploration of
diabetic ketoacidosis as potential etiology. Stimuli were
modified to improve the image quality after case feedback.
References/suggestions for further reading:
1. Podrid PJ. Pathophysiology and etiology of sudden cardiac
arrest. In: Olshansky B, Manaker S, Downey BC, eds.
UpToDate. Waltham, MA: UpToDate Inc.
https://www.uptodate.com/contents/pathophysiology-
and-etiology-of-sudden-cardiac-arrest. Updated Apr 18,
2018.
2. Kline JA. Venous Thromboembolism. In: Tintinalli JE,
Stapczynski JS, Ma OJ, et al, eds. Tintinalli’s Emergency
Medicine: A Comprehensive Study Guide. 8th ed. New York,
NY: McGraw-Hill; 2016:388-398.
3. Kasper W, Konstantinides S, Geibel A, et al. Management
strategies and determinants of outcome in acute major
pulmonary embolism: results of a multicenter registry. J Am
Coll Cardiol. 1997;30(5):1165-1171.
4. Sharifi M, Berger J, Beeston P, Bay C, Vajo Z, Javadpoor S.
Pulseless electrical activity in pulmonary embolism treated
with thrombolysis (from the “PEAPETT” study). Am J Emerg
List of Resources:
Abstract
1
User Guide
3
Instructor Materials
5
Operator Materials
15
Debriefing and Evaluation Pearls
18
Simulation Assessment
21
Learner Audience:
Senior residents
Time Required for Implementation:
Instructor Preparation: 30-60 minutes
Time for case: 15-30 minutes
Time for debriefing: 15-30 minutes
Recommended Number of Learners per Instructor:
1
Topics:
Pulseless electrical activity (PEA), syncope, cardiac arrest, Hs
and Ts from ACLS PEA instruction, tPA for massive PE, critical
care medicine, simulation.
Objectives:
By the end of this simulation session, the learner will be able
to:
1. Identify PEA arrest
2. Review the ACLS commonly recognized PEA arrest
etiologies via the H &T mnemonic
3. Review and discuss the risks and benefits of (tPA)
for massive PE
USER GUIDE
eturn: Calibri Size 10
Sembroski E, et al. Pulseless Electrical Activity Cardiac Arrest. JETem 2020. 5(1):S1-25.
https://doi.org/10.21980/J8Z055
4
Med. 2016;34(10):1963-1967. doi:
10.1016/j.ajem.2016.06.094.
5. Wan S, Quinlan D, Agnelli G, Eikelboom J. Thrombolysis
compared with heparin for the initial treatment of
pulmonary embolism: a meta-analysis of the randomized
controlled trials. Circulation. 2004;13(11):38-39. doi:
10.1161/01.CIR.0000137826.09715.9C.
6. DePalo VA, Kharnaf AE. Venous Thromboembolism (VTE)
Treatment & Management. In: Medscape. Panchbhavi VK,
ed. https://emedicine.medscape.com/article/1267714-
treatment#d10 Published June 12, 2019. Accessed July 2,
2019.
7. Kline JA. Pulmonary embolism and deep vein thrombosis.
In: Walls RM, Hockberger RS, Gausche-Hill M, et al. Rosen’s
Emergency Medicine: Concepts and Clinical Practice. 9th ed.
Philadelphia, PA: Elsevier; 2018:1051-1065.
8. Nickson C. Thrombolysis for submassive pulmonary
embolus. Life in the FastLane.
https://litfl.com/thrombolysis-for-submassive-pulmonary-
embolus/. Published June 9, 2019. Accessed July 2, 2019.
9. Shah SN, Kharnaf AE. Pulseless Electrical Activity. In:
Medscape. Dizon JM, ed.
https://emedicine.medscape.com/article/161080-
overview. Published March 27, 2018. Accessed October 30,
2019.
10. Tapson VF, Weinberg AS. Thrombolytic (fibrinolytic)
therapy in acute pulmonary embolism and lower extremity
deep vein thrombosis. In: Mandel J, Finlay G, eds.
UpToDate. Waltham, MA: UpToDate Inc.
https://www.uptodate.com/contents/search?search=thro
mbolytic-fibrinolytic-therapy-in-acute-pulmonary-
embolism-and-lower-extremity-deep-veinthrombosis.
Updated May 3, 2019.
11. Tapson VF, Weinberg AS. Treatment, prognosis, and follow-
up of acute pulmonary embolism in adults. In: Mandel J,
Hockberger RS, Finlay G, eds. UpToDate. Waltham, MA:
UpToDate Inc.
https://www.uptodate.com/contents/treatment-
prognosis-and-follow-up-of-acute-pulmonary-embolism-in-
adults. Updated Dec 12, 2019.
Section Break
INSTRUCTOR MATERIALS
eturn: Calibri Size 10
Sembroski E, et al. Pulseless Electrical Activity Cardiac Arrest. JETem 2020. 5(1):S1-25.
https://doi.org/10.21980/J8Z055
5
Case Title: Pulseless Electrical Activity Cardiac Arrest
Case Description & Diagnosis (short synopsis): Patient is a 40-year-old female brought in by
EMS for a suspected syncopal episode after being found unconscious. She was awake and alert
at time of EMS arrival but grew increasingly agitated. Paramedics have grown frustrated with
her agitation, and her agitation continues upon arrival. She will complain of pain but will not
localize and grows progressively distressed. The patient is unable to provide further detailed
history, though her family confirms she began birth control in the last few months. She is
negative for any other PE risk factors. While in the emergency department she grows
increasingly tachypneic, tachycardic, and hypoxic, eventually requiring intubation. Following
intubation her blood pressure and pulse are lost and she has a PEA arrest. Participants will
need to consider possible etiologies for PEA arrest and implement a treatment strategy. If Hs
& Ts are not fully discussed, learners will be verbally prompted by an embedded participant.
Participants should establish the diagnosis of massive PE. Ultrasound (US) confirms dilated
right ventricle, and participants should discuss the risk and benefits of tPA administration.
Embedded participant will prompt the tPA discussion if necessary as well. Participants should
then administer tPA, after which they will obtain return of spontaneous circulation (ROSC).
Participants may then order computed tomography (CT), which reveals massive PE with
bilateral segmental emboli. If participants fail to follow ACLS guidelines, establish the diagnosis
of PE, or fail to administer tPA, the patient will proceed to asystole and death.
Equipment or Props Needed:
High fidelity simulator
Infusion pump
IV pole
Cardiac monitor/defibrillator
Crash cart & medications
Intubation equipment
tPA
Confederates needed:
Nurse
Paramedic (control room)
Pharmacist (control room)
Family member (control room)
INSTRUCTOR MATERIALS
eturn: Calibri Size 10
Sembroski E, et al. Pulseless Electrical Activity Cardiac Arrest. JETem 2020. 5(1):S1-25.
https://doi.org/10.21980/J8Z055
6
Stimulus Inventory:
#1 Electrocardiogram (ECG)
#2 Chest Radiograph (CXR)
#3 Ultrasound/Echocardiogram
#4 Computed Tomography (CT)
#5 Basic Metabolic Profile
#6 Lactic Acid
#7 Venous Blood Gas
Background and brief information: The scenario occurs in the emergency department at a
tertiary care center. The patient is a 40-year-old female brought in by EMS for a suspected
syncopal episode. The patient was found unconscious on bathroom floor at work by coworker.
She was awake and alert at time of EMS arrival but grew increasingly agitated. Paramedics
have grown frustrated with her agitation and refusal to cooperate with their assessment, and
this continues on their arrival. She will complain of pain but will not localize and grows
progressively distressed in the emergency department. The patient is unable to provide
further detailed history, though her family will confirm that she began birth control in the last
few months. She is negative for any other PE risk factors. While in the emergency department
she grows increasingly tachypneic, tachycardic, and hypoxic, eventually requiring intubation.
Following intubation her blood pressure and pulse are lost and she has a PEA arrest.
Participants will need to consider possible etiologies for PEA arrest and implement a treatment
strategy. If Hs & Ts are not fully discussed, learners will be verbally prompted by an embedded
participant.
Initial presentation: Patient is brought in by EMS, who appear frustrated with the patient’s
lack of cooperation. She is alert, but in severe distress. She is oriented to self but otherwise
minimally able to cooperate with history and exam. She is tachypneic and complains of pain
and discomfort but cannot localize cause of her distress. She is very agitated, attempting to
remove her gown and oxygen mask.
How the scenario unfolds: This patient has a massive PE. Paramedics will be present at the
beginning of the case and will give her presenting history in a calm, dismissive tone. The
participants should recognize that the patient is sicker than this report suggests and establish
IV access, place the patient on the monitor, and apply oxygen. Laboratory and bedside imaging
(CXR/US) may be requested at this time, but participants will be told the patient is too
unstable for CT. Other than the agitation, tachycardia, and respiratory distress, the exam is
INSTRUCTOR MATERIALS
eturn: Calibri Size 10
Sembroski E, et al. Pulseless Electrical Activity Cardiac Arrest. JETem 2020. 5(1):S1-25.
https://doi.org/10.21980/J8Z055
7
largely unremarkable. The patient quickly grows increasingly distressed, tachypneic and
tachycardic and eventually hypoxic. If the participants do not elect to intubate early, the
patient will become progressively hypoxic until this decision is reached (if they attempt to
place BiPAP, they will be told that the patient tears it off). Following intubation, the patient
has a rapid decline in blood pressure, eventually resulting in loss of pulses and a PEA arrest.
The participants should then verbalize Hs and Ts or another approach to determining
reversible causes of PEA arrest. The patient will remain in PEA arrest as long as the participants
follow ACLS. The participants should identify a massive PE as the most likely cause of the arrest
and administer tPA (100 mg IV over two hours). The patient will then have ROSC. Bedside US
should be available and if asked for will show right ventricular dilation. Following ROSC and
stabilization, if the participants request a CT this will show PE with bilateral segmental emboli.
The learners should then discuss with the ICU for admission.
Critical actions:
1. Establish IV access, place the patient on the monitor, and apply oxygen
2. Recognize critically ill patient
3. Intubate
4. Recognize PEA arrest and perform ACLS
5. Discuss reversible causes of PEA
6. Establish diagnosis of PE
7. Administer tPA
8. Admit to ICU
INSTRUCTOR MATERIALS
eturn: Calibri Size 10
Sembroski E, et al. Pulseless Electrical Activity Cardiac Arrest. JETem 2020. 5(1):S1-25.
https://doi.org/10.21980/J8Z055
8
Case Title: Pulseless Electrical Activity Cardiac Arrest
Chief Complaint: Arrives via EMS. Found in bathroom pale after possible syncope vs. seizure.
Vitals: Heart Rate (HR) 137 Blood Pressure (BP) 110/68 Respiratory Rate (RR) 23
Temperature (T) 36.9°C Oxygen Saturation (O2Sat) 76% on room air (RA)
General Appearance: 40-year-old female who appears agitated, mottled and dyspneic.
Primary Survey:
• Airway: moaning and making incomprehensible noises but not able to state her name
when asked
• Breathing: rather tachypneic, increased work of breathing
• Circulation: pale, cool extremities; no palpable distal pulses
History:
• History of present illness: 40-year-old female presents in acute respiratory distress. Per
EMS she was found on the bathroom floor by a family member after a loss of
consciousness. Initially, they were called for a possible seizure, but on arrival, the
patient was agitated and combative. She reports pain and severe trouble breathing but
is unable to localize her pain. Her family member arrives and provides history that the
patient is on birth control.
• Past medical history: Attention deficit disorder
• Past surgical history: none
• Patient’s medications: oral contraceptive pills, amphetamine 20mg
• Allergies: No known allergies (NKDA)
• Social history: negative for tobacco or recreational drug usage. Occasional alcohol
consumption
• Family history: unremarkable
Secondary Survey/Physical Examination:
• General appearance: patient appears tachypneic and in significant respiratory distress
• HEENT:
o Head: normocephalic, atraumatic
o Eyes: Pupils equal and reactive bilaterally
o Ears: Within normal limits (WNL)
INSTRUCTOR MATERIALS
eturn: Calibri Size 10
Sembroski E, et al. Pulseless Electrical Activity Cardiac Arrest. JETem 2020. 5(1):S1-25.
https://doi.org/10.21980/J8Z055
9
o Nose: WNL
o Throat: WNL
• Neck: WNL
• Heart: tachycardic, no murmurs/rubs/gallops
• Lungs: diminished but present lung sounds bilaterally; no rales. Severe respiratory
distress noted.
• Abdominal/GI: soft, mild diffuse tenderness to palpation; no guarding/rebound
• Genitourinary: N/A
• Rectal: N/A
• Extremities: WNL
• Back: WNL
• Neuro: alert to self only, otherwise uncooperative
• Skin: pale/mottled
• Lymph: WNL
• Psych: agitated, barely conscious
INSTRUCTOR MATERIALS
eturn: Calibri Size 10
Sembroski E, et al. Pulseless Electrical Activity Cardiac Arrest. JETem 2020. 5(1):S1-25.
https://doi.org/10.21980/J8Z055
10
Results:
Electrocardiogram (ECG)
(author’s own image)
INSTRUCTOR MATERIALS
eturn: Calibri Size 10
Sembroski E, et al. Pulseless Electrical Activity Cardiac Arrest. JETem 2020. 5(1):S1-25.
https://doi.org/10.21980/J8Z055
11
Chest Radiograph (CXR)
(author’s own image)
If chest x-ray is ordered early in the case, learners will be informed it is on the way. CXR can be
taken following intubation, arrest, and tPA and is shown below.
INSTRUCTOR MATERIALS
eturn: Calibri Size 10
Sembroski E, et al. Pulseless Electrical Activity Cardiac Arrest. JETem 2020. 5(1):S1-25.
https://doi.org/10.21980/J8Z055
12
Ultrasound/Echocardiogram
(author’s own image)
INSTRUCTOR MATERIALS
eturn: Calibri Size 10
Sembroski E, et al. Pulseless Electrical Activity Cardiac Arrest. JETem 2020. 5(1):S1-25.
https://doi.org/10.21980/J8Z055
13
Computed Tomography (CTA)
(author’s own image)
Following arrest, tPA, resuscitation, and ROSC, a CTA may be requested, with image below:
Impression:
1. Extensive pulmonary embolism as described with right ventricular strain
2. Large areas of consolidation in the right lung and to a lesser degree in the left lower lobe
indicating pneumonia
3. Periportal edema in the liver and mild ascites
4. Fluid surrounding the pancreas suspicious for acute pancreatitis
5. A 3 cm gastric mass in the distal stomach suspicious for a neoplasm
INSTRUCTOR MATERIALS
eturn: Calibri Size 10
Sembroski E, et al. Pulseless Electrical Activity Cardiac Arrest. JETem 2020. 5(1):S1-25.
https://doi.org/10.21980/J8Z055
14
Basic metabolic panel (BMP)
Sodium 140 mEq/L
Chloride 101 mEq/L
Potassium 3.6 mEq/L
Bicarbonate (HCO3) 18 mEq/L
Blood Urea Nitrogen (BUN) 13 mg/dL
Creatine (Cr) 1.1 mg/dL
Glucose 160 mg/dL
Ionized Calcium 4.4 mg/dL
Lactic Acid 4.1 mEq/L
Venous Blood Gas (VBG)
pH 7.1
PaCO2 57 mmHg
PaO2 48 mmHg
Bicarbonate (HCO3) 16.9 mEq/L
O2 saturation, arterial 79%
If further labs are requested, the learners should be informed that lab is running them.
OPERATOR MATERIALS
eturn: Calibri Size 10
Sembroski E, et al. Pulseless Electrical Activity Cardiac Arrest. JETem 2020. 5(1):S1-25.
https://doi.org/10.21980/J8Z055
15
SIMULATION EVENTS TABLE:
Minute (state)
Participant
action/ trigger
Patient status (simulator response) & operator
prompts
Monitor display
(vital signs)
0:00
(Baseline)
Participants enter
the room.
Patient is lying on stretcher, agitated, tachypneic.
Paramedics are at bedside to give report. Should
be given in a casual/dismissive tone.
Not on monitor
01:00
Assess ABCs
Place patient on
monitor
Establish IV access
Place patient on
supplemental
oxygen
Attempt further
history from EMS
and patient,
perform exam
A: Patient is alert, oriented to self, protecting her
airway, speaking and moaning in pain.
B: Tachypneic, breathing in high 20s. In severe
respiratory distress but with clear lung sounds.
C: She is tachycardic, pale, mottled, but with
adequate initial blood pressure.
When placed on supplemental O2 nonrebreather
(NRB) patient is adamant it be removed, states “I
can’t breathe.”
She is able to say her name, but otherwise does
not answer questions. Only states “it hurts” and “I
can’t breathe.” Does not localize pain when asked.
T 36.9°C
HR 137
BP 110/68
RR 23
O2 76% room air
03:00
(Initial
Resuscitation)
Begin IV fluids
Oxygen
supplementation
Obtain ECG
Obtain labs
Tachycardia and blood pressure will stabilize with
IVF; however, she will not improve.
Patient continues to require increasing amount of
supplemental oxygen.
ECG provided.
Participants will be provided with labs if requested
and should be prompted for them when IV is
started if they do not request labs.
Despite adequate resuscitation the patient’s
condition continues to decline. Oxygenation
worsens despite NRB and patient will not tolerate
BiPAP.
Tachycardia and hypoxia should continue to
progress until decision is made to intubate.
T 36.6°C
HR 150
BP 96/50
RR 32
O2 88% NRB
OPERATOR MATERIALS
eturn: Calibri Size 10
Sembroski E, et al. Pulseless Electrical Activity Cardiac Arrest. JETem 2020. 5(1):S1-25.
https://doi.org/10.21980/J8Z055
16
Minute (state)
Participant
action/ trigger
Patient status (simulator response) & operator
prompts
Monitor display
(vital signs)
Decision to
intubate
Proceed to intubation state.
05:00
(Delay in
treatment)
Despite IV fluids
Despite Oxygen
supplementation
No Decision to
Intubate
Tachycardia increases and blood pressure
decreases.
Hypoxia worsens.
Patient arrests—proceed to arrest state.
T 36.6°C
HR 162
BP 84/41
RR 35
O2 75% nasal
cannula
05:00
Intubation
Prepare for
intubation:
- Suction
- Bag-valve
mask
- Induction
agent
- Paralytic
Patient should be
reevaluated
following
intubation
Patient paralyzed and sedated.
Following intubation, patient’s HR decreases
steadily into 70s. BP should be rechecked and is no
longer obtainable.
Proceed to arrest state.
T 36.6°C
HR 162
BP 102/51
RR 12
O2 92%
ventilator
T 36.6°C
HR 74
BP–
RR 12
O2 80%
ventilator
10:00
PEA Arrest
Begin CPR and
progress through
ACLS for
treatment of PEA
Arrest
Discussion of
Reversible causes
(Hs and Ts)
Administer tPA
Patient remains in PEA arrest with unchanged
condition.
Participants may need to be prompted for this
discussion while progressing through ACLS.
Disparity between patient’s presentation of
tachypnea and respiratory acidosis/hypoxia should
be discussed. Patient’s family member may be
interviewed and will confirm that she is on birth
control.
Proceed to ROSC.
T 36.6°C
HR PEA bagged
BP–
RR 12
O2 60%
ventilator
OPERATOR MATERIALS
eturn: Calibri Size 10
Sembroski E, et al. Pulseless Electrical Activity Cardiac Arrest. JETem 2020. 5(1):S1-25.
https://doi.org/10.21980/J8Z055
17
Minute (state)
Participant
action/ trigger
Patient status (simulator response) & operator
prompts
Monitor display
(vital signs)
15:00
No tPA
Administered
Continue CPR,
ACLs
Administer tPA
If tPA is not given for presumed PE, patient will
progress to asystole and family member will ask
for team to “stop everything.”
Proceed to ROSC.
15:00
ROSC
Request for
pressor infusion
Obtain bedside US
and CXR if not
done so already
Call for CTA
Initiate Heparin
Infusion
Blood pressure stabilizes, HR increases.
Provide CXR and US images as requested.
Provide CT images and reports.
T 36.6°C
HR 96
BP 112/60
RR 12
O2 90%
ventilator
(Case
Completion)
Call ICU for
admission
ICU accepts the patient.
Case Ends
Diagnosis:
Massive PE; PEA arrest with ROSC
Disposition:
Admission to the medical ICU.
DEBRIEFING AND EVALUATION PEARLS
eturn: Calibri Size 10
Sembroski E, et al. Pulseless Electrical Activity Cardiac Arrest. JETem 2020. 5(1):S1-25.
https://doi.org/10.21980/J8Z055
18
PEA Arrest
Pearls:
Reversible Causes:
Hs and Ts
- Hypovolemia, hypoxia, hydrogen ions (acidosis), hypokalemia, hyperkalemia,
Hypoglycemia, Hypothermia
- Toxins, tamponade (cardiac), tension pneumothorax, thromboembolism (pulmonary or
cardiac)
Alternate Approach
Fix with airway
- Hypoxia
- Acidosis (if respiratory)
Fix with a needle
- Tension pneumothorax
- Cardiac tamponade
Fix with an IV
- Hypovolemia – fluid, blood
- Hyperkalemia – calcium, bicarbonate, insulin
- Hypokalemia – potassium/magnesium
- Acidosis (if metabolic) – bicarb
- Hypoglycemia - dextrose
- Massive PE – tPA
- Toxins – antidote
Fix with Dialysis
- Hyperkalemia
- Acidosis
- Toxins
Fix with warming
- Hypothermia
Fix with tPA or heart catheterization
- Acute myocardial infarction
ECG findings of PE
- S1Q3T3 associated with PE (S1Q3 seen on case ECG)
- Most commonly sinus tachycardia
DEBRIEFING AND EVALUATION PEARLS
eturn: Calibri Size 10
Sembroski E, et al. Pulseless Electrical Activity Cardiac Arrest. JETem 2020. 5(1):S1-25.
https://doi.org/10.21980/J8Z055
19
- Signs of Right heart strain including Right bundle branch block
Ultrasound Findings
- Right ventricular dilation
- Hyperdynamic cardiac function
- McConnell’s sign (relative hyperkinesis of apex of right ventricle)
Other debriefing points:
- Discuss the index of suspicion created on entering the room. Report by EMS and their
causal air in contrast to patient’s appearance. How quickly was safety net established and
did initial vitals change participant’s perception of the case?
- Discuss the treatment and evaluation of PEA arrest, including progression through
analyzing reversible causes and what factors change index of suspicion for each one.
- Discuss the dosing of tPA in massive PE.
- Why did this patient arrest after intubation? (blunting catecholamine response)
- If bedside US was not obtained, discuss how else this patient’s likelihood of PE could have
been assessed.
- What are this patient’s risk factors for PE vs other causes of PEA? What about her
presentation suggested PE?
Further reading:
1. DePalo VA, Kharnaf AE. Venous Thromboembolism (VTE) Treatment & Management. In:
Medscape. Panchbhavi VK, ed. https://emedicine.medscape.com/article/1267714-
treatment#d10. Published June 12, 2019. Accessed July 2, 2019.
2. Kline JA. Pulmonary Embolism and Deep Vein Thrombosis. Rosen’s Emergency Medicine:
Concepts and Clinical Practice. 9th ed. Philadelphia, PA: Elsevier, Inc.; 2018.
https://www-clinicalkey com.siumed.idm.oclc.org/#!/content/book/3-s2.0-
B9780323354790000787?indexOverride=GLOBAL. Accessed October 30, 2019.
3. Nickson C. Thrombolysis for submassive pulmonary embolus. In: Life in the FastLane.
https://litfl.com/thrombolysis-for-submassive-pulmonary-embolus/. Published June 9,
2019. Accessed July 2, 2019.
4. Shah SN, Kharnaf AE. Pulseless Electrical Activity. In: Medscape. Dizon, JM, ed.
https://emedicine.medscape.com/article/161080-overview. Published March 27, 2018.
Accessed October 30, 2019.
5. Tapson VF, Weinberg AS. Thrombolytic (fibrinolytic) therapy in acute pulmonary
embolism and lower extremity deep vein thrombosis. In UpToDate, Mandel J, Finlay G,
eds. UpToDate, Waltham, MA, 2019.
DEBRIEFING AND EVALUATION PEARLS
eturn: Calibri Size 10
Sembroski E, et al. Pulseless Electrical Activity Cardiac Arrest. JETem 2020. 5(1):S1-25.
https://doi.org/10.21980/J8Z055
20
https://www.uptodate.com/contents/search?search=thrombolytic-fibrinolytic-therapy-
in-acute-pulmonary-embolism-and-lower-extremity-deep-veinthrombosis. Updated
May 3, 2019.
6. Tapson VF, Weinberg AS. Treatment, prognosis, and follow-up of acute pulmonary
embolism in adults. In UpToDate, Mandel J, Hockberger RS, Finlay G, eds.
UpToDate, Waltham, MA, 2019. https://www.uptodate.com/contents/treatment-
prognosis-and-follow-up-of-acute-pulmonary-embolism-in-adults. Updated Dec 12,
2019.
SIMULATION ASSESSMENT
PEA Arrest
Learner: _________________________________________
eturn: Calibri Size 10
Sembroski E, et al. Pulseless Electrical Activity Cardiac Arrest. JETem 2020. 5(1):S1-25.
https://doi.org/10.21980/J8Z055
21
Assessment Timeline
This timeline is to help observers assess their learners. It allows observer to make notes on when learners
performed various tasks, which can help guide debriefing discussion.
Critical Actions:
1. Establish IV access, place patient on
monitor, apply oxygen
2. Recognize critically ill patient
3. Establish definitive airway
4. Recognize PEA arrest and performed
ACLS
5. Discuss reversible causes of PEA
6. Establish diagnosis of PE
7. Administer tPA
8. Admit to ICU
0:00
SIMULATION ASSESSMENT
PEA Arrest
Learner: _________________________________________
Standardized assessment form for simulation cases. JETem ã Developed by: Megan Osborn, MD, MHPE;
Shannon Toohey, MD; Alisa Wray, MD
Sembroski E, et al. Pulseless Electrical Activity Cardiac Arrest. JETem 2020. 5(1):S1-25.
https://doi.org/10.21980/J8Z055
22
Critical Actions:
Established IV access, place patient on monitor, apply oxygen
Recognized critically ill patient and began resuscitation early
Established definitive airway
Performed ACLS and recognized PEA arrest
Discussed reversible causes of PEA
Establish diagnosis of PE
Administer tPA
Patient admitted to ICU
Summative and formative comments:
SIMULATION ASSESSMENT
PEA Arrest
Learner: _________________________________________
Standardized assessment form for simulation cases. JETem ã Developed by: Megan Osborn, MD, MHPE;
Shannon Toohey, MD; Alisa Wray, MD
Sembroski E, et al. Pulseless Electrical Activity Cardiac Arrest. JETem 2020. 5(1):S1-25.
https://doi.org/10.21980/J8Z055
23
Milestones assessment:
Milestone
Did not
achieve
level 1
Level 1
Level 2
Level 3
1
Emergency
Stabilization (PC1)
Did not achieve
Level 1
Recognizes abnormal vital
signs
Recognizes an unstable patient,
requiring intervention
Performs primary assessment
Discerns data to formulate a
diagnostic impression/plan
Manages and prioritizes
critical actions in a critically ill
patient
Reassesses after implementing
a stabilizing intervention
2
Performance of
focused history and
physical (PC2)
Did not achieve
Level 1
Performs a reliable,
comprehensive history
and physical exam
Performs and communicates a
focused history and physical
exam based on chief complaint
and urgent issues
Prioritizes essential
components of history and
physical exam given dynamic
circumstances
3
Diagnostic studies
(PC3)
Did not achieve
Level 1
Determines the necessity
of diagnostic studies
Orders appropriate diagnostic
studies.
Performs appropriate bedside
diagnostic studies/procedures
Prioritizes essential testing
Interprets results of diagnostic
studies
Reviews risks, benefits,
contraindications, and
alternatives to a diagnostic
study or procedure
4
Diagnosis (PC4)
Did not achieve
Level 1
Considers a list of
potential diagnoses
Considers an appropriate list of
potential diagnosis
May or may not make correct
diagnosis
Makes the appropriate
diagnosis
Considers other potential
diagnoses, avoiding premature
closure
SIMULATION ASSESSMENT
PEA Arrest
Learner: _________________________________________
Standardized assessment form for simulation cases. JETem ã Developed by: Megan Osborn, MD, MHPE;
Shannon Toohey, MD; Alisa Wray, MD
Sembroski E, et al. Pulseless Electrical Activity Cardiac Arrest. JETem 2020. 5(1):S1-25.
https://doi.org/10.21980/J8Z055
24
Milestone
Did not
achieve
level 1
Level 1
Level 2
Level 3
5
Pharmacotherapy
(PC5)
Did not achieve
Level 1
Asks patient for drug
allergies
Selects an medication for
therapeutic intervention,
consider potential adverse
effects
Selects the most appropriate
medication and understands
mechanism of action, effect,
and potential side effects
Considers and recognizes
drug-drug interactions
6
Observation and
reassessment (PC6)
Did not achieve
Level 1
Reevaluates patient at
least one time during case
Reevaluates patient after most
therapeutic interventions
Consistently evaluates the
effectiveness of therapies at
appropriate intervals
7
Disposition (PC7)
Did not achieve
Level 1
Appropriately selects
whether to admit or
discharge the patient
Appropriately selects whether to
admit or discharge
Involves the expertise of some of
the appropriate specialists
Educates the patient
appropriately about their
disposition
Assigns patient to an
appropriate level of care
(ICU/Tele/Floor)
Involves expertise of all
appropriate specialists
9
General Approach to
Procedures (PC9)
Did not achieve
Level 1
Identifies pertinent
anatomy and physiology
for a procedure
Uses appropriate
Universal Precautions
Obtains informed consent
Knows indications,
contraindications, anatomic
landmarks, equipment,
anesthetic and procedural
technique, and potential
complications for common ED
procedures
Determines a back-up strategy
if initial attempts are
unsuccessful
Correctly interprets results of
diagnostic procedure
SIMULATION ASSESSMENT
PEA Arrest
Learner: _________________________________________
Standardized assessment form for simulation cases. JETem ã Developed by: Megan Osborn, MD, MHPE;
Shannon Toohey, MD; Alisa Wray, MD
Sembroski E, et al. Pulseless Electrical Activity Cardiac Arrest. JETem 2020. 5(1):S1-25.
https://doi.org/10.21980/J8Z055
25
Milestone
Did not
achieve
level 1
Level 1
Level 2
Level 3
20
Professional Values
(PROF1)
Did not achieve
Level 1
Demonstrates caring,
honest behavior
Exhibits compassion, respect,
sensitivity and responsiveness
Develops alternative care
plans when patients’ personal
beliefs and decisions preclude
standard care
22
Patient centered
communication (ICS1)
Did not achieve
level 1
Establishes rapport and
demonstrates empathy to
patient (and family)
Listens effectively
Elicits patient’s reason for
seeking health care
Manages patient expectations
in a manner that minimizes
potential for stress, conflict,
and misunderstanding.
Effectively communicates with
vulnerable populations, (at
risk patients and families)
23
Team management
(ICS2)
Did not achieve
level 1
Recognizes other
members of the patient
care team during case
(nurse, techs)
Communicates pertinent
information to other healthcare
colleagues
Communicates a clear,
succinct, and appropriate
handoff with specialists and
other colleagues
Communicates effectively with
ancillary staff
