can you pronounce someone in PEA dead?

[Painter1]

elderly patient presented in arrest. downtown for like 25minutes.

intubated, round of ACLS now with pulse.

family then decides to make patient dnr but in the interim to leave mechanical ventilation.

patient goes into PEA and remains in PEA. patient remains cold with fixed pupils. how long do you wait to prounounce the patient dead?

no offense, but if ure a student can you preface your comment by stating you're a student.

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[Altruist]

elderly patient presented in arrest. downtown for like 25minutes.

intubated, round of ACLS now with pulse.

family then decides to make patient dnr but in the interim to leave mechanical ventilation.

patient goes into PEA and remains in PEA. patient remains cold with fixed pupils. how long do you wait to prounounce the patient dead?

no offense, but if ure a student can you preface your comment by stating you're a student.

Student here, was a paramedic prior to that if that's worth anything. This was recently discussed in another thread in this very forum. Summary: Check with ultrasound. If no ventricular movement, call 'em.

If they're DNR, no pulse, in PEA, and no ultrasound around... I'd talk to the family, then turn off the monitor & unhook the vent.

 

[Arcan57]

Yes, you can.

 

[erin682]

I had this issue on some icu months as an intern. Nurses would try to tell me I couldn't declare death until asystole. That's wrong and has to do with their paperwork and not real medicine.

 

[bulgethetwine]

I had this issue on some icu months as an intern. Nurses would try to tell me I couldn't declare death until asystole. That's wrong and has to do with their paperwork and not real medicine.

You know what else? If they have a warm (but dead) heart, and a PACER, there may still appear to be PEA on the monitor.

By the way, putting a magnet over the box only shuts off the shock function of an AICD. Eventually, heart will be no longer able to conduct an electrical signal even thought the pacer is still firing.

Lots of pacers in the graveyard keeping the beat.....

 

[kungfufishing]

of course you can.

 

[n2b8me]

😉

 

[TysonCook]

Yes. Turn off the monitor.

 

[dchristismi]

You can pronounce someone in VF too. Not done often, but done.

 

[docB]

Yes, you can.

I had this issue on some icu months as an intern. Nurses would try to tell me I couldn't declare death until asystole. That's wrong and has to do with their paperwork and not real medicine.

This is true. Where I've seen it become an issue is with nurses who HAVE to record asystole in 2 leads for the chart. I had them try the "But you can't call the code until we can get 2 leads of asystole." thing on me. So I said "Whatever. I'm leaving. Give it 10 minutes and I'm sure you'll have your asystole." That's one advantage you have as an attending rather than a student or resident.😎

 

[hakksar]

Do it quite regularly, usually throw the U/S on the heart first to demonstrate no real cardiac contraction despite electrical activity though. Plus you can rule out tamponade as a cause by doing that. No problems with the nurses here though.

 

[leviathan]

I had one case with a guy in vfib arrest. We got him back into some sort of idioventricular rhythm with faint pulses, but eventually it was no longer palpable. By the time we rolled into the ED it was already at about the 25 min mark, and the EP called it 10 mins later while he was still in that PEA rhythm. No ultrasound done, but labs were done and his pH was somewhere in the 6 range.

 

[ArkansasRanger]

Yes, you can.



This is true. Where I've seen it become an issue is with nurses who HAVE to record asystole in 2 leads for the chart. I had them try the "But you can't call the code until we can get 2 leads of asystole." thing on me. So I said "Whatever. I'm leaving. Give it 10 minutes and I'm sure you'll have your asystole." That's one advantage you have as an attending rather than a student or resident.😎

lol

I love that.

 

[Aloha Kid]

For many of the codes we get in the ED, the difficulty is that we as doctors understand the extreme futility with many of the cases. We are not obliged to treat in these situations, yet we still sometimes feel compelled even though we have a pretty good idea of what the outcome will be.

 

[ER-ER-Oh]

I personally carry a stick in these situations. If they look dead I poke 'em with the stick. If it feels dead with the stick I call it.

 

[Dwindlin]

I personally carry a stick in these situations. If they look dead I poke 'em with the stick. If it feels dead with the stick I call it.

👍

 

[deleted6669]

You can pronounce someone in VF too. Not done often, but done.

yup, when I was a medic we had a guy in VF traumatic arrest for > 40 min and called him in VF shortly after his chest hair started smoking from the multiple defibs.

 

[Dwindlin]

yup, when I was a medic we had a guy in VF traumatic arrest for > 40 min and called him in VF shortly after his chest hair started smoking from the multiple defibs.

Wow, we don't even work trauma arrests (no matter the rhythm) here unless they arrest after we're already enroute to the ED.

 

[deleted6669]

Wow, we don't even work trauma arrests (no matter the rhythm) here unless they arrest after we're already enroute to the ED.

it was 1992 and he initially had weak carotid pulses then emd/pea in the field then went into vf enroute.

 

[docB]

it was 1992 and he initially had weak carotid pulses then emd/pea in the field then went into vf enroute.

We were all so cute and innocent back then.😀

 

[Jeff698]

We were all so cute and innocent back then.😀

I seem to remember thinking that the massive doses of epi I was pushing were actually doing something good for the patient. Ah, the days....

Take care,
Jeff

 

[Dwindlin]

I seem to remember thinking that the massive doses of epi I was pushing were actually doing something good for the patient. Ah, the days....

Take care,
Jeff

Wait...are you saying its not? 🙁

 

[GeneralVeers]

Back to the OP: What would your alternative be instead of pronouncing them "dead"?

Would you run a code for an hour if need be on a futile code until every last vestige of electrical activity was gone from the monitor?

 

[Arcan57]

This thread has way more in the way of legs than I thought it would. Of note, if a patient no longer has a heart they can't be in PEA.

 

[docB]

This thread has way more in the way of legs than I thought it would. Of note, if a patient no longer has a heart they can't be in PEA.

You mean like if they've had some massive thoracic trauma and the heart is lying on the ground next to them? Then that's true. But do you have to try to resuscitate the heart if it's in PEA?😀

 

[roja]

Yes
You can also call a code for medical futility.

 

[Arcan57]

You mean like if they've had some massive thoracic trauma and the heart is lying on the ground next to them? Then that's true. But do you have to try to resuscitate the heart if it's in PEA?😀

It would be useful for teaching med students and junior residents how to do a cardioectomy. You know, in case you have to do an emergent heart transplant in the ED.

BTW, your question put in the image in my head of somebody using the heart like a stress ball while screaming "LIVE!"

 

[docB]

BTW, your question put in the image in my head of somebody using the heart like a stress ball while screaming "LIVE!"

Which would be really cool if they were wearing the Dr. Frankenstein style button up the side tunic while they did it.

 

[GeneralVeers]

Which would be really cool if they were wearing the Dr. Frankenstein style button up the side tunic while they did it.

Those are cool. Why don't we wear those anymore?

 

[AbbyNormal]

You mean like if they've had some massive thoracic trauma and the heart is lying on the ground next to them? Then that's true. But do you have to try to resuscitate the heart if it's in PEA?😀

made me think of Raiders of the Lost Ark when the thugee priest removes a pumping heart. talimi talimi, hoomunshimi hoomunshimi

 

[GeneralVeers]

made me think of Raiders of the Lost Ark when the thugee priest removes a pumping heart. talimi talimi, hoomunshimi hoomunshimi

"Indy! Cover your heart!"

 

[jbar]

You have betrayed Shiva.

 

[Paseo Del Norte]

elderly patient presented in arrest. downtown for like 25minutes.

intubated, round of ACLS now with pulse.

family then decides to make patient dnr but in the interim to leave mechanical ventilation.

patient goes into PEA and remains in PEA. patient remains cold with fixed pupils. how long do you wait to prounounce the patient dead?

no offense, but if ure a student can you preface your comment by stating you're a student.

Nurse here, but I'm an RT student:

I agree with a quick US. No motion, call it IMHO. PEA is a rather terminal rhythm IMHO and I have never had problem utilising a strip of PEA in my documentation. Frankly, as a nurse, the sooner the doc calls, the easier my job becomes regardless of the final documented rhythm.

In the field without US, I would code for a few minutes, document good CPR, tube placement and look for any easy to treat causes, primarily for a nice chart and so I can relay an accurate report to medical direction when I call for termination orders.