Case Study: “MIS-PEA”

A 76-year old male has been transported into your emergency department by the paramedics. You have been advised that the patient “has a long history of COPD”. You conduct a rapid assessment and note the following:  BP = 158/90, pulse = 132, respiratory frequency = 52/minute. His skin color is pale, and he is using all accessory muscles of respiration. Because of his severe dyspnea, he is unable to answer any questions. The paramedics state that he has been given “2 nebulizers” (albuterol) prior to admission resulting in no improvement. During your assessment, you observe signs indicating his level of consciousness is beginning to rapidly deteriorate.

You lower the back of the cart placing the patient in a supine position and begin to assist his respiratory efforts using a bag/mask device with 100% oxygen. Suddenly the patient began to violently cough making the assisted ventilation difficult. His mucous membranes became noticeably cyanotic. As you struggled to assist his ventilation, you note that he has become apneic. A team member announces “there is no pulse”. You look up at the monitor and observe a narrow QRS rhythm at a rate of about 140.

Pursuant to the ACLS algorithm for Pulseless Electrical Activity (PEA), chest compressions are initiated and the patient is intubated. The resident intubating the patient states that breath sounds are impossible to hear “because of the COPD, mucous and bronchospasm.” He also states that the patient’s lungs are very “stiff and non-compliant”. 1.0 m.g. of epinephrine is administered via an antecubital I.V. line. The ECG monitor has changed to a very slow idio-venticular rhythm. Still there is no pulse. CPR is continued and 3 additional 1.0 m.g. doses of I.V. epinephrine are administered. Based on the ECG showing asystole, and the arrest has had a duration of >15 minutes, the decision is made to stop resuscitative efforts. The patient is pronounced dead.

Significant Autopsy Findings

1. extensive lung deterioration due to severe chronic emphysema

2. significant increase in lung volume

3. significant right cardiac hypertrophy

4. left sided tension pneumothorax

Comment

If PEA is a symptom of a dying myocardium, survival is nil. However, there are underlying conditions which may cause PEA, and have the potential for survival. Probably the most common is the tension pneumothorax. Resolution simply requires decompression of the affected side of the chest. Although there are various types of pneumothoraces, only the tension pneumothorax is associated with a sudden loss of pulse. Patients developing this condition do so as a side-effect of positive airway pressure. CPR and epinephrine cannot reverse a tension pneumothorax. At large needle or surgical blade can.