Things You Need to Know About PEA

  • Updated on: July 9, 2024

Table of content(s)


  1. Introduction
  2. How common is PEA arrest?
  3. What is PEA?
  4. What causes PEA?
  5. What are the symptoms of PEA?
  6. Diagnosis of pulseless electrical activity 
  7. What is the difference between PEA and asystole? 
  8. Treatment for PEA in ACLS
  9. Conclusion


Approximately 300,000 out-of-hospital cardiac arrests occur in the United States. The survival rate is around 8%. The initial rhythm may be ventricular fibrillation, asystole, or pulseless electrical activity. Around two-thirds of out of hospital cardiac arrests have a non-shockable rhythm of PEA, or asystole. It has an increasing incidence as compared with initial shockable rhythms. 

PEA is an especially serious heart arrhythmia related to undetectable electrical activity. Its symptoms require immediate medical attention. Keep reading the blog to find out everything you need to know about PEA, including PEA treatment in ACLS. 


How common is PEA arrest?

PEA arrests are a common occurrence in the hospital setting. A study found that 68% of tracked in-hospital deaths and 10% of all in-hospital deaths are due to pulse electrical activity. A PEA arrest is the first documented rhythm in 38% of adults experiencing hospital cardiac arrest. In a hospital setting, approximately 20–30% of cardiac arrests occur. This makes it a common initial rhythm encountered during cardiac arrest. 

The reason may be the underlying cause, the overall health status, the promptness of the intervention, etc. You can reduce survival rates compared to other kinds of arrest rhythms, especially when they are not identified and treated. 


What is PEA?

PEA is a clinical condition characterized by a lack of palpable pulse and unresponsiveness. Earlier, PEA was referred to as electromechanical dissociation. A lack of ventricular electrical activity implies a lack of ventricular mechanical activity. Electrical activity is crucial, but not sufficient for mechanical activity. During cardiac arrest, ventricular electrical activity is not accompanied by meaningful ventricular mechanical activity. 

True PEA is a condition where cardiac contractions are absent in the presence of coordinated electrical activity. PEA involves organized cardiac rhythms, which include supraventricular rhythms and ventricular rhythms. Do not equate the absence of peripheral pulses with PEA. This is because it may be due to several other peripheral vascular diseases.

Read more: ACLS Drugs For Bradycardia


What causes PEA?

PEA occurs when the heart suffers major trauma, such as a heart attack. It can also occur when a condition affects metabolism, respiration, or circulation, causing an abnormal heart rhythm. 


Here are a few causes of PEA:

  • High levels of acid in the bloodstream
  • Dehydration 
  • High or low potassium levels 
  • Low levels of oxygen in the organs
  • Body temperature drops below 95 degrees F (35 degrees Celsius).
  • Chest trauma
  • Cardiac tamponade 
  • Heart toxins 
  • Tension pneumothorax

Individuals over the age of 70 face the risk of PEA. This is especially true among females.


What are the symptoms of PEA?

A patient with PEA will be unconscious with no pulse and not breathing. It leads to a loss of cardiac output. The blood supply is discontinued and does not reach the brain. Thus, the skin appears pale due to the insufficient oxygen in the blood. Ensure that you check for a pulse at the carotid artery. Stay alert for heart sounds by using a stethoscope. 

To summarize, here are the primary symptoms of PEA:

  • Electrical activity is detectable on an EKG. 
  • No heartbeat is detectable with a stethoscope. 
  • Pauses in breathing 
  • No pulse 


Diagnosis of pulseless electrical activity 

An electrocardiogram device can successfully distinguish PEA from other causes of cardiac arrest. The ECG interpretation can appear to be the same as a normal sinus rhythm. Hence, in PEA, it is crucial to treat the symptoms of the patient and not just the rhythm on the monitor. The absence of a pulse thus ensures a clinical diagnosis of cardiac arrest. There is no use with an orderly cardiac arrest ECG rhythm such as asystole ventricular tachycardia and ventricular fibrillation.

Read More: A Guide to Understanding ECG Artifacts


What is the difference between PEA and asystole? 


Feature Pulseless electrical activity  Systole
ECG appearance Organized electrical complexes on ECG without a pulse. Flat Line on ECG
Mechanical activity Does not have any mechanical activity  No mechanical activity 
Treatment focus Identifying and addressing reversible causes  Initiation of high quality CPR and ACLS in PEA protocols. 
Common causes Hypoxia, toxins, hypovolemia, cardiac tamponade.  Severe trauma, end-stage cardiac disease, massive pulmonary embolism


Treatment for PEA in ACLS

Cardiopulmonary resuscitation is one of the first steps to treating PEA, especially in an out-of-hospital setting. If you suspect PEA, you must administer CPR. If you do not know the skills, reach out to someone who knows how to perform pulseless electrical activity treatment in ACLS


Here are other methods of treatment of PEA in ACLS:

  1. Pay attention to the ECG rhythm: The H’s and T’s mnemonic list all the possible causes of PEA. However, it does not provide much guidance. The ECG rhythm can give you insight into the reasons for PEA cardiac arrest. 
  2. Inspect the medical history of the patients: Pay attention to the characteristics of the ECG rhythm. This can narrow the field of possibilities. However, assessing the medical history and performing a physical exam are crucial to identifying the causes of PEA. 
  3. Get a 12-lead PEA: If the diagnosis does not point towards any of the possible H and T causes, then stop CPR and acquire a 12-lead ECG. You can place the precordial electrodes while performing chest compressions. If the cause of arrest is elusive, then the information acquired from 12-lead can help. 
  4. Investigate point-of-care ultrasound: Point-of-care ultrasound has several uses in the prehospital setting. Look at the inferior vena cava. Looking at the lungs can help identify patients with a tension pneumothorax. 



The term PEA refers to pulseless electrical activity. This condition needs prompt recognition and treatment. Identify the symptoms, know the causes, and PEA treatment in ACLS. This helps enhance survival rates and the quality of care during emergencies.