Pulseless  electrical activity cardiac arrest: time to amend the mnemonic “4H&4T”?

Ludovic Beun; Bertrand Yersin; Joseph Osterwalder; Pierre-Nicolas Carron

doi:10.4414/smw.2015.14178

Original article

Vol. 145 No. 3132 (2015)

Pulseless electrical activity cardiac arrest: time to amend the mnemonic “4H&4T”?

Ludovic Beun
Bertrand Yersin
Joseph Osterwalder
Pierre-Nicolas Carron

DOI: https://doi.org/10.4414/smw.2015.14178
Cite this as:: Swiss Med Wkly. 2015;145:w14178
Published: 26.07.2015

Summary

BACKGROUND:Pulseless electrical activity (PEA) cardiac arrest is characterised by a residual organised electrical activity. PEA is frequently induced by reversible conditions. The mnemonic “4H&4T” was proposed as a reminder to assess for Hypoxia, Hypovolaemia, Hypo/Hyperkalaemia, Hypothermia, Thrombosis, cardiac Tamponade, Toxins, and Tension pneumothorax. Other potential aetiologies have been identified, but their respective probability and frequencies are unclear. The aim of this study was to analyse the aetiologies of PEA out-of-hospital cardiac arrests and to evaluate their relative frequencies.

METHODS: This was a retrospective study based on data routinely and prospectively collected. All adult patients with PEA as the first recorded rhythm and admitted between 2002 and 2012 to the emergency department (ED) after return of spontaneous circulation or under resuscitation were included.

RESULTS: A total of 1,866 out-of-hospital cardiac arrests were included. PEA was the first recorded rhythm in 232 adult patients (12.4%) and 144 of these were admitted to the ED. The mean age was 63.8 ± 20.0 years, 58.3% were men. The survival rate at 48 hours was 29%. Hypoxia (23.6%), acute coronary syndrome (12.5%) and trauma (12.5%) were the most frequent causes. We were unable to identify a specific cause in 17.4%. Pulmonary embolism, hypovolaemia, intoxication and hypo/hyperkalaemia occurred in fewer than 10% of the cases. Nonischaemic cardiac disorders and intracranial haemorrhage occurred in 8.3% and 6.9%, respectively.

CONCLUSIONS: Intracranial haemorrhage and nonischaemic cardiac disorders represent significant causes of PEA, with a prevalence equalling or exceeding the frequency of classical 4H&4T aetiologies. These conditions are potentially accessible to simple diagnostic procedures (computed tomography or echocardiography).

References

Myerburg RJ, Halperin H, Egan DA, Boineau R, Chugh SS, Gillis AM, et al. Pulseless electric activity: definition, causes, mechanisms, management, and research priorities for the next decade: report from a National Heart, Lung, and Blood Institute workshop. Circulation 2013;128(23):2532–41.
Mehta C, Brady W. Pulseless electrical activity in cardiac arrest: electrocardiographic presentations and management considerations based on the electrocardiogram. Am J Emerg Med. 2012;30(1):236–9.
Deakin CD, Nolan JP, Soar J, Sunde K, Koster RW, Smith GB, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 4. Adult advanced life support. Resuscitation. 2010;81(10):1305–52.
Parish DC, Dinesh Chandra KM, Dane FC. Success changes the problem: why ventricular fibrillation is declining, why pulseless electrical activity is emerging, and what to do about it. Resuscitation. 2003;58(1):31–5.
Mader TJ, Nathanson BH, Millay S, Coute RA, Clapp M, McNally B. Out-of-hospital cardiac arrest outcomes stratified by rhythm analysis. Resuscitation. 2012;83(11):1358–62.
Väyrynen T, Kuisma M, Määttä T, Boyd J. Who survives from out-of-hospital pulseless electrical activity? Resuscitation. 2008;76:207–13.
Kajino K, Iwami T, Daya M, Nishiuchi T, Hayashi Y, Ikeuchi H, et al. Subsequent ventricular fibrillation and survival in out-of-hospital cardiac arrests presenting with PEA or asystole. Resuscitation. 2008;79:34–40
Neumar RW, Otto CW, Link MS, Kronick SL, Shuster M, Callaway CW, et al. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(18 Suppl 3):S729–767.
Kloeck WG. A practical approach to the aetiology of pulseless electrical activity. A simple 10-step training mnemonic. Resuscitation. 1995;30(2):157–9.
Mitsuma W, Ito M, Kodama M, Takano H, Tomita M, Saito N, et al. Clinical and cardiac features of patients with subarachnoid haemorrhage presenting with out-of-hospital cardiac arrest. Resuscitation. 2011;82(10):1294–7.
Arnaout M, Mongardon N, Deye N, Legriel S, et al. Out-of-hospital cardiac arrest from brain cause: epidemiology, clinical features, and outcome in a multicenter cohort. Crit Care Med. 2015;43:453–60
Coba V, Jaehne AK, Suarez A, Dagher GA, Brown SC, Yang JJ, et al. The incidence and significance of bacteremia in out of hospital cardiac arrest. Resuscitation. 2014;85(2):196–202.
Florance R, Tong N, Giubileo A, Lloyd C. Suggested change to Resuscitation Council guidelines on reversible causes of cardiac arrest: acute subarachnoid haemorrhage, and malignant tachyarrhythmia. Resuscitation. 2013;84(1):e17.
Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest (new abridged version). The “Utstein style”. The European Resuscitation Council, American Heart Association, Heart and Stroke Foundation of Canada, and Australian Resuscitation Council. Br Heart J. 1992;67(4):325–33.
Virkkunen I, Paasio L, Ryynänen S, Vuori A, Sajantila A, Yli-Hankala A, et al. Pulseless electrical activity and unsuccessful out-of-hospital resuscitation: what is the cause of death? Resuscitation. 2008;77(2):207–10.
Saarinen S, Nurmi J, Toivio T, Fredman D, Virkkunen I, Castrén M. Does appropriate treatment of the primary underlying cause of PEA during resuscitation improve patients’ survival? Resuscitation. 2012;83(7):819–22.
Breitkreutz R, Walcher F, Seeger FH. Focused echocardiographic evaluation in resuscitation management: concept of an advanced life support-conformed algorithm. Crit Care Med. 2007;35(Suppl 5):S150–161.
Lockey, David J. et al. Development of a simple algorithm to guide the effective management of traumatic cardiac arrest. Resuscitation. 2012;84(6):738–42.
Lockey D, Crewdson K, Davies G. Traumatic cardiac arrest: who are the survivors? Ann Emerg Med. 2006;48(3):240–4.
Lewandowski P. Subarachnoid haemorrhage imitating acute coronary syndrome as a cause of out-of-hospital cardiac arrest - case report. Anaesthesiol Intensive Ther. 2014;46(4):289–92.
Comess KA, DeRook FA, Russell ML, Tognazzi-Evans TA, Beach KW. The incidence of pulmonary embolism in unexplained sudden cardiac arrest with pulseless electrical activity. Am J Med. 2000;109(5):351–6.
Courtney DM, Sasser HC, Pincus CL, Kline JA. Pulseless electrical activity with witnessed arrest as a predictor of sudden death from massive pulmonary embolism in outpatients. Resuscitation. 2001;49(3):265–72.

How to Cite

1.

Beun L, Yersin B, Osterwalder J, Carron P-N. Pulseless electrical activity cardiac arrest: time to amend the mnemonic “4H&4T”?. Swiss Med Wkly [Internet]. 2015 Jul. 26 [cited 2024 Nov. 24];145(3132):w14178. Available from: https://smw.ch/index.php/smw/article/view/2053

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

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[1] Myerburg RJ, Halperin H, Egan DA, Boineau R, Chugh SS, Gillis AM, et al. Pulseless electric activity: definition, causes, mechanisms, management, and research priorities for the next decade: report from a National Heart, Lung, and Blood Institute workshop. Circulation 2013;128(23):2532–41.

[2] Mehta C, Brady W. Pulseless electrical activity in cardiac arrest: electrocardiographic presentations and management considerations based on the electrocardiogram. Am J Emerg Med. 2012;30(1):236–9.

[3] Deakin CD, Nolan JP, Soar J, Sunde K, Koster RW, Smith GB, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 4. Adult advanced life support. Resuscitation. 2010;81(10):1305–52.

[4] Parish DC, Dinesh Chandra KM, Dane FC. Success changes the problem: why ventricular fibrillation is declining, why pulseless electrical activity is emerging, and what to do about it. Resuscitation. 2003;58(1):31–5.

[5] Mader TJ, Nathanson BH, Millay S, Coute RA, Clapp M, McNally B. Out-of-hospital cardiac arrest outcomes stratified by rhythm analysis. Resuscitation. 2012;83(11):1358–62.

[6] Väyrynen T, Kuisma M, Määttä T, Boyd J. Who survives from out-of-hospital pulseless electrical activity? Resuscitation. 2008;76:207–13.

[7] Kajino K, Iwami T, Daya M, Nishiuchi T, Hayashi Y, Ikeuchi H, et al. Subsequent ventricular fibrillation and survival in out-of-hospital cardiac arrests presenting with PEA or asystole. Resuscitation. 2008;79:34–40

[8] Neumar RW, Otto CW, Link MS, Kronick SL, Shuster M, Callaway CW, et al. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(18 Suppl 3):S729–767.

[9] Kloeck WG. A practical approach to the aetiology of pulseless electrical activity. A simple 10-step training mnemonic. Resuscitation. 1995;30(2):157–9.

[10] Mitsuma W, Ito M, Kodama M, Takano H, Tomita M, Saito N, et al. Clinical and cardiac features of patients with subarachnoid haemorrhage presenting with out-of-hospital cardiac arrest. Resuscitation. 2011;82(10):1294–7.

[11] Arnaout M, Mongardon N, Deye N, Legriel S, et al. Out-of-hospital cardiac arrest from brain cause: epidemiology, clinical features, and outcome in a multicenter cohort. Crit Care Med. 2015;43:453–60

[12] Coba V, Jaehne AK, Suarez A, Dagher GA, Brown SC, Yang JJ, et al. The incidence and significance of bacteremia in out of hospital cardiac arrest. Resuscitation. 2014;85(2):196–202.

[13] Florance R, Tong N, Giubileo A, Lloyd C. Suggested change to Resuscitation Council guidelines on reversible causes of cardiac arrest: acute subarachnoid haemorrhage, and malignant tachyarrhythmia. Resuscitation. 2013;84(1):e17.

[14] Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest (new abridged version). The “Utstein style”. The European Resuscitation Council, American Heart Association, Heart and Stroke Foundation of Canada, and Australian Resuscitation Council. Br Heart J. 1992;67(4):325–33.

[15] Virkkunen I, Paasio L, Ryynänen S, Vuori A, Sajantila A, Yli-Hankala A, et al. Pulseless electrical activity and unsuccessful out-of-hospital resuscitation: what is the cause of death? Resuscitation. 2008;77(2):207–10.

[16] Saarinen S, Nurmi J, Toivio T, Fredman D, Virkkunen I, Castrén M. Does appropriate treatment of the primary underlying cause of PEA during resuscitation improve patients’ survival? Resuscitation. 2012;83(7):819–22.

[17] Breitkreutz R, Walcher F, Seeger FH. Focused echocardiographic evaluation in resuscitation management: concept of an advanced life support-conformed algorithm. Crit Care Med. 2007;35(Suppl 5):S150–161.

[18] Lockey, David J. et al. Development of a simple algorithm to guide the effective management of traumatic cardiac arrest. Resuscitation. 2012;84(6):738–42.

[19] Lockey D, Crewdson K, Davies G. Traumatic cardiac arrest: who are the survivors? Ann Emerg Med. 2006;48(3):240–4.

[20] Lewandowski P. Subarachnoid haemorrhage imitating acute coronary syndrome as a cause of out-of-hospital cardiac arrest - case report. Anaesthesiol Intensive Ther. 2014;46(4):289–92.

[21] Comess KA, DeRook FA, Russell ML, Tognazzi-Evans TA, Beach KW. The incidence of pulmonary embolism in unexplained sudden cardiac arrest with pulseless electrical activity. Am J Med. 2000;109(5):351–6.

[22] Courtney DM, Sasser HC, Pincus CL, Kline JA. Pulseless electrical activity with witnessed arrest as a predictor of sudden death from massive pulmonary embolism in outpatients. Resuscitation. 2001;49(3):265–72.