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Pulseless Electrical Activity


Pulseless Electrical Activity (PEA) Rhythm

PEA rhythm occurs when any heart rhythm that is observed on the electrocardiogram (ECG) does not produce a pulse. PEA can come in many different forms. Sinus Rhythm, tachycardia, and bradycardia can all be seen with PEA.

Performing a pulse check after a rhythm/monitor check will ensure that you identify PEA in every situation.

Pulseless electrical activity usually has an underlying treatable cause. The most common cause in emergency situations is hypovolemia.

PEA is treated by assessing and correcting the underlying cause. These causes can be summed up in the 6 H’s and 6 T’s of ACLS. Use the link to review the H’s and T’s.

When an underlying cause for pulseless electrical activity cannot be determined, PEA should be treated in the same fashion as asystole

Pulseless electrical activity is treated using the right branch of the puslesless arrest arrest algorithm. Click below to view the pulseless arrest algorithm diagram. When done click again to close the diagram.
Pulseless Arrest Algorithm Diagram.


Question #1: If you saw the rhythm below after defibrillation, how would you determine if it is pulseless electrical activity?
EKG of Sinus Rhythm with PVC's
click here for answer

Question #2: What is the most common cause of PEA?
click here for answer

You should check for a carotid or femoral pulse

  66 Responses to “Pulseless Electrical Activity”

  1. Hi Jeff,

    I’m confused about 3 things. First if PEA/Asystole is not shockable why is there a rhythm shockable check in the right branch of the pulseless arrest algorithm? So, it’s possible for someone who’s PEA/Asystole after 5 cycles of CPR and administration of epi that the rhythm is now shockable. In that case would it be a synchronized shock (cardioversion)?
    Second, does one shock unit deliver either an unsynchronized shock (defibrillation) or a synchronized shock (cardioversion). Just wondering if you can switch between the two on the same unit rather than having two units if you know what I mean. And when someone says ‘Get the defibrillator’ does that mean it will only deliver unsynchronized shocks? Sorry about all of these elementary questions. Thanks!!

    • Question #1:
      In the right branch of the pulseless arrest algorithm when performing a rhythm check, you are looking for a change. If you see VF you would shock. If you see VT with no pulse then you would shock (defibrillation). If you see any other rhythm that could have a pulse, you would perform a pulse check. If no pulse then you would continue CPR.

      Questions #2:
      The same defibrillator unit will deliver either a synchronized (cardioversion) or unsynchronized shock (defibrillation). You have to set it for the one that you will be performing. This will depend upon your assessment.
      “Get the Defibrillator” means get the machine that delivers energy. It will do both synchronized cardioversion or unsynchronized cardioversion.

      This might help: Synchronized Cardioversion VS. Unsynchronized Cardioversion
      Kind regards, Jeff

  2. Now I decided to leave book
    Everything is easy here
    Thank you very much

  3. its wonderfull, i had a patient who arrested due to septic shock with hypotension. she had a heart rate of 132/min. It was sinus tachycardia with no pulse absolutely. What rhythm can it be?

    • PEA. In this case, you would use the right branch of the pulseless arrest algorithm and also treat the cause of the PEA. It sounds like the cause would be septic shock and resulting hypotension.
      Kind regards,

  4. If pt have no pulse,no BP and monitor shows tachy, can we say that monitor is showing sinus tachyrdia rate of 130?

  5. Why we will not use defibrillator on PEA??

  6. Are there any situations where it is recommended to shock (unsynchronized shock-defibrillation) a patient with a pulse (besides symptomatic patient-synchronized cardioversion)?

    • Here are the situations where you would use synchronized cardioversion, pulseless ventricular tachycardia, ventricular fibrillation, and polymorphic ventricular tachycardia that will not sync for synchronized cardioversion.
      There are other reasons why you would use synchronized cardioversion for tachycardia other than unstable tachycardia. The two most common are atrial fibrillation and atrial flutter.
      Kind regards,

      • Jeff, did you mean to say that situations requiring UNsynchronized cardioversion {defibrillation} would include “pulseless ventricular tachycardia, ventricular fibrillation, and polymorphic ventricular tachycardia that will not sync for synchronized cardioversion”?

        In class, I teach that a patient in a rhythm of Torsades de Pointes, who is unstable with a pulse, requires immediate unsynchronized cardioversion {defibrilliation}, since the rotating R-waves won’t readily sync.

        Thank you for providing an excellent resource to which I can direct students!

      • You are teaching correctly. Torsades de Pointes is a form of polymorphic ventricular tachycardia that will require UNsynchronized cardioversion.
        Kind regards,

  7. Let’s say I am not with the Pt at the moment, how do I know the Pt has no Pulse if he is doing well on the monitor? does the monitor able to show me “0″ pulse?

    • There is no way to tell that the patient has a pulse from just looking at a rhythm.

      The monitor may show you other things that would indicate to you that the patient has a pulse. Many monitors have the capability of monitoring chest rise and fall.

      If the chest is rising and falling this is an indication of respiration. If the patient is breathing, then patient has a pulse.

      Also many monitoring system today have pulse oximetry which monitors oxygen saturation. The oxygen saturation level uses a detector that senses the blood pulsing through the cardiovascular system which is indicated with a waveform that shows the pulse rate. So this would also indicate a pulse.

      Again, if you are just looking at the rhythm, this will not tell you anything about whether a patient has a pulse or not.

      Kind regards,

  8. Hi! Just want to clarify,Hypoglycemia and Trauma are not included anymore in the H’s and T’s ? Tnx.

    • That is correct. Hypoglycemia and Trauma are not included in the H’s and T’s. They are both considered important aspects of assessment for ACLS, but they were removed from the H’s and T’s.

      Kind regards,

  9. will a bundle branch block make what is actually a narrow complex tachy actually look more like a wide complex tachy? will this potentially lead down the wrong protocol path?

    • Yes, a BBB can make a narrow complex tachycardia look like a wide complex tachycardia. This is beyond the scope of basic ACLS. Here is a link to a very good article that provides detailed information regarding this issue.
      Kind regards,

  10. does Vfib does not have pulse?

    if it doesnt, is it considered a PEA? and PEA is not shockable, what shall be the management?

    • VF does not have a pulse. VF and VT are the exceptions to PEA. Technically, VF and VT is electrical activity but they respond well to shocks so they are treated differently than every other type of PEA. VT and VF are treated with the left branch of the pulseless arrest algorithm and PEA/Asystole is treated with the right branch of the pulseless arrest algorithm.

      Kind regards,

  11. Is A-fib considered an organized rhythm? Can A-fib present as PEA?

    • A-fib is considered an organized rhythm if the patient has a pulse. This is because both the atrial and the ventricles are involved and coordinating together and it generates a pulse.
      A-fib without a pulse and for that matter any rhythm does not have a pulse would be considered PEA.

      Kind regards,

  12. I love your website, it is so easy to understand, I am a nurse and always have students.. this site is very helpful when I need to teach my students about codes.
    thank you.

  13. This site is supper! Am ready for my interview tomorrow thank you i polished up

  14. This site has really helped me sort out all of the ACLS info. I work in an outpatient surgery center and in 7 yrs have only seen 1 arrest. This makes it more real and easier to remember.

  15. Jeannie Daniel has a typo in her response. The normal QRS interval IS NOT 0.6-0.1 seconds, it is 0.06-0.1 seconds.

    • Thanks for pointing out the error on the measurement with reference to a comment on the site. I have edited that comment to show the correct QRS interval of 0.06 – 0.10 s.
      Thanks for pointing that out.
      Kind regards,

  16. what is the clue that PEA is caused by a drug overdose?

  17. Thank you ..very well explained and simple to follow

  18. many thanks for discussion, it help me more

  19. Very helpful. Thanks Jeff.


    • You are most likely referring to an anomaly seen on an ECG called a bundle branch block.

      A bundle branch block refers to a defect in the hearts electrical conduction system.

      With a bundle branch block, when the heart’s electrical activity begins in the SA Node (sionatrial node), the impulse travels down through the AV node (atrioventricular node) from the AV node, the impulse travels down the “Bundle of His” and divides into the right and left bundle branches.

      When one of these branches becomes injured, it slows or blocks the conduction of electricity. The electricity has to go somewhere so it results in altered pathways for ventricular depolarization.

      This causes the ECG to look different. The most common difference seen is a Wide QRS due to the increased conduction time. A bundle branch block can be diagnosed when the duration of the QRS complex exceeds 120 ms.

      Hope this helps.
      Kind regards,

      • Dear Jeff,
        You state that the BBB is diagnosed when the duration of the QRS exceeds 120ms. Since the QRS is always mapped in s (seconds), this reference is confusing. You should explain that the 120ms = 0.12s. Furthermore, you should add that the normal QRS interval is 0.06s – 0.10s. Technically, an incomplete BBB will measure between 0.10s – 0.12s. 0.12s will measure three small boxes on the ECG paper. Each small box is 0.04s. Complete BBB will measure greater than 0.12s. These BBB can be constant or intermittent.

        Jeannie Daniel RN, BSN ICU

    • You and this site is a blessing!!!!!!!!!!!!!!!!!

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