Ep 131 PEA Arrest, PseudoPEA and PREM – With Simard and Weingart

In this EM Cases Episode 131 PEA Arrest, PseudoPEA and PREM with Rob Simard of POCUS Cases fame and the co-author of The POCUS Pulse Check paper and Scott Weingart, we go beyond ACLS and guide you through the complex world of Pulseless Electrical Activity (PEA). We discuss the notion that the palpation technique is poor at determining whether or not a patient has a pulse, that the POCUS pulse is more accurate and as rapid, compared to the palpation technique, at determining whether or not a patient has a pulse, the difference between true PEA arrest, PseudoPEA and PREM, why epinephrine may be harmful in PEA, Weingart's chain of survival approach from PEA arrest to Return of Spontaneous Circulation (ROSC), four tools to help differentiate true PEA arrest from PseudoPEA or ROSC, how to prevent long pauses in chest compressions using POCUS, EM Cases PEA arrest and PseudoPEA suggested dynamic algorithm, vasopressor choices in PseudoPEA, whether the "QRS wide vs narrow width" approach to PEA arrest underlying cause is useful or not and much more... Podcast production, sound design & editing by Anton Helman Written Summary and blog post by Anton Helman October, 2019 Cite this podcast as: Helman, A. Simard, R. Weingart, S. PEA Arrest, PseudoPEA and PREM. Emergency Medicine Cases. October, 2019. https://emergencymedicinecases.com/pea-arrest-pseudopea-prem. Accessed [date] The palpation technique is poor at determining whether or not a patient has a pulse In a study assessing the diagnostic accuracy of first responders of detecting a manual pulse in patient with and without a true pulse, the sensitivity for pulselessness approached 90%, however the specificity was only 55%. Only 15% of participants could accurately assess for the presence of a pulse within 10 seconds and only 2% identified pulselessness correctly within 10 seconds. A study of EM and ICU physicians and nurses attempting manual pulse determination in healthy subjects demonstrated that 43% of participants required more than 5 seconds to detect the pulse. An observational study of 105  healthcare providers showed that only 38% correctly identified a pulse and only 9% correctly identified pulselessness within 10 seconds by palpation method. "Humans are reliably unreliable at finding pulses with their fingers" - Scott Weingart The POCUS pulse is more accurate and as rapid compared to the palpation technique at determining whether or not a patient has a pulse A 2019 RCT of 111 health care providers with 15 minutes of US training in detecting carotid pulses looked at time to carotid pulse detection and rates of prolonged pulse checks (>5 or 10 seconds), showed no significant differences between POCUS pulse check and manual pulse check in the rates of prolonged pulse checks of greater than 5 or 10 seconds. First attempt at detection of a pulse was more successful in the POCUS group (99.1% vs 85.6%). In a case series comparing POCUS pulse checks with manual pulse checks POCUS pulse checks were consistently performed in < 5 seconds and clearly determinate, even when palpation yields indeterminate results. Update 2020 A study of patients looked at accuracy of POCUS pulse check. They compiled a library of 10-second clips of the common carotid artery at high-, medium- and low-SBPs and pulseless clips while on bypass. They then showed these clips to critical care physicians and asked them to answer whether or not there was a pulse within 10 seconds, using the arterial line trace as the gold standard. Twenty-three patients had all four videos collected.