2008 Oct. 61(10):371-3. Hs Hypovolemia. Finally, the Hs and Ts should always be considered in the aftermath of a code in attempt to ascertain why the patient coded in the first place. Advanced Cardiac Life Support (ACLS) Certification Course, Ventricular Fibrillation and Pulseless Ventricular Tachycardia, Adult Immediate Post-Cardiac Arrest Care Algorithm. 2009 Feb. 26(2):145-6. 2017 Oct 9.. . Each case of PEA is unique and the rhythm seen on the monitor will therefore differ from case to case. [Guideline] Neumar RW, Otto CW, Link MS, et al. If you log out, you will be required to enter your username and password the next time you visit. Steven J Compton, MD, FACC, FACP Director of Cardiac Electrophysiology, Alaska Heart Institute, Providence and Alaska Regional Hospitals, Steven J Compton, MD, FACC, FACP is a member of the following medical societies: Alaska State Medical Association, American College of Cardiology, American College of Physicians, American Heart Association, American Medical Association, and Heart Rhythm Society, David S Marks, MD Director of Cardiac Catheterization Laboratory, Froedtert Memorial Lutheran Hospital; Associate Professor, Department of Internal Medicine, Section of Cardiology, Medical College of Wisconsin, David S Marks, MD is a member of the following medical societies: American College of Cardiology, American Heart Association, American Medical Association, Medical Association of Georgia, and Society for Cardiac Angiography and Interventions, Patrick O'Beirne, MD Fellow in Cardiovascular Medicine, University of Massachusetts Memorial Medical Center, Patrick O'Beirne, MD is a member of the following medical societies: American College of Cardiology, American Medical Association, Massachusetts Medical Society, and Phi Beta Kappa, Dionyssios A Robotis, MD, MPH, FACC Clinical Associate Professor of Medicine, University of Massachusetts Medical School; Consulting Staff Cardiologist/Electrophysiologist, University of Massachusetts Memorial Medical Center, Dionyssios A Robotis, MD, MPH, FACC is a member of the following medical societies: American College of Cardiology, Cardiac Electrophysiology Society, Heart Rhythm Society, and Massachusetts Medical Society, Lawrence Rosenthal, MD, PhD, FACC, FHRS Associate Professor of Medicine, Director, Section of Cardiac Pacing and Electrophysiology, Director of EP Fellowship Program, Division of Cardiovascular Disease, University of Massachusetts Memorial Medical Center, Lawrence Rosenthal, MD, PhD, FACC, FHRS is a member of the following medical societies: American College of Cardiology, American Heart Association, and Massachusetts Medical Society, Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference, Eric Vanderbush, MD, FACC Chief, Department of Internal Medicine, Division of Cardiology, Harlem Hospital Center; Clinical Assistant Professor of Cardiology, Columbia University College of Physicians and Surgeons, Eric Vanderbush, MD, FACC is a member of the following medical societies: American College of Cardiology and American Heart Association, Sumit Verma, MD, FACC Staff Electrophysiologist, Cardiology Consultants, Pensacola Heart Institute, Sumit Verma, MD, FACC is a member of the following medical societies: American College of Cardiology. Emerg Med J. It is essential to search for and treat reversible causes for resuscitative efforts to be successful. It is important to CONFIRM true PEA early in the management of the case. Manage as non-shockable rhythm. For non-shockable cardiac arrest: CPR 2min + Adrenaline ↓ Check rhythm, if non-shockable ↓ CPR 2min ↓ Check rhythm, if non-shockable ↓ … 2017 Nov. 120:103-7. [Medline]. In some situations it can be possible to identify and treat a reversible cause. 2017 Oct 9. Instantaneous nonarrhythmic cardiac death in acute myocardial infarction. Resuscitation. 300 mg bolus Healthcare providers should attempt to identify and correct an underlying cause if present. Be sure to look for evidence of these problems as you assess the patient. 2014 Jul-Sep. 34(3):133-8; quiz 139-40. First documented rhythm and clinical outcome from in-hospital cardiac arrest among children and adults. 2008 Nov. 18(11):1121-3. Treatment of PEA is not limited to the interventions outlined in the algorithm. [Medline]. Circulation. For patients with a shockable rhythm, the literature supports prioritizing defibrillation and CPR initially and giving epinephrine if initial attempts with CPR and defibrillation are not successful. AHA Advanced Cardiovascular Life Support Provider Manual, p. 113. 2018 Feb. 123:58-64. [Medline]. Of sixteen observational studies on timing in the recent systematic review, all found an association between earlier epinephrine and ROSC for patients with non-shockable rhythms, although improvements in survival were not universally seen. ... (PEA). They are also the most easily reversible and should be at the top of any differential diagnosis. 132 (18 suppl 2):S444-64. 2015 Oct. 95:100-47. PEA is one of many waveforms by ECG (including sinus rhythm) without a detectable pulse. Steiger HV, Rimbach K, Muller E, Breitkreutz R. Focused emergency echocardiography: lifesaving tool for a 14-year-old girl suffering out-of-hospital pulseless electrical activity arrest because of cardiac tamponade. Hypovolemia and hypoxia are the two most common causes of PEA. It represents a lack of electrical activity in the heart. Resuscitation. Am J Cardiol. Any rhythm including a flat line (asystole). Pulseless electrical activity (PEA), asystole, ventricular fibrillation (VFib or VF), and ventricular tachycardia (VTach or VT) may have a reversible cause in your patient (though most often PEA). ECG-based classification of resuscitation cardiac rhythms for retrospective data analysis. PEA may include any pulseless waveform with the exception of VF, VT, or asystole (Figure 28). For instance, hypovolemia, flow-restricting emboli, hypoxia, and metabolic conditions may lead to PEA. There is a need for quality bag-mask ventilation, with the use of … Hypovolemia and hypoxia are the 2 most common underlying and potentially reversible causes of PEA. 76(3):376-80. Arti N Shah, MD, MS, FACC, FACP, CEPS-AC, CEDS Assistant Professor of Medicine, Mount Sinai School of Medicine; Director of Electrophysiology, Elmhurst Hospital Center and Queens Hospital Center J Electrocardiol. Be sure to look for evidence of these problems as you assess the patient. They are also the most easily reversible and should be at the top of any differential diagnosis. PEA is one of any number of ECG waveforms (even sinus rhythm) but without a detectable pulse. [Medline]. Epinephrine is still the best choice according to 2020 guidelines. Jose M Dizon, MD is a member of the following medical societies: American College of Cardiology, Heart Rhythm SocietyDisclosure: Nothing to disclose. 10(4):526-30. Combined with effective CPR and defibrillation, this maximises the chances of the patient surviving the cardiac arrest. [Medline]. Eur J Emerg Med. The H’s and T’s of ACLS is a mnemonic used to help recall the major contributing factors to pulseless arrest including PEA, Asystole, Ventricular Fibrillation, and Ventricular Tachycardia. 122 (18 suppl 3):S729-67. Asystole is a flat-line ECG (Figure 27). [Medline]. A simplified and structured teaching tool for the evaluation and management of pulseless electrical activity. The H's and T's that are possible causes of PEA include all the following except: A. hypovolemia, toxins, thrombosis B. hypoxia, thrombocytopenia, hypoglycemia C. hypothermia, tension pneumothorax, hydrogen ion (acidosis) D. hydrogen ion, hypokalemia, tamponade This website also contains material copyrighted by 3rd parties. Jose M Dizon, MD Associate Professor of Clinical Medicine, Clinical Electrophysiology Laboratory, Division of Cardiology, Columbia University College of Physicians and Surgeons; Assistant Attending Physician, Department of Medicine, C\New York-Presbyterian/Columbia University Medical Center Resuscitation. If the individual has a return of spontaneous circulation (ROSC), proceed to post-cardiac arrest care. [Guideline] Link MS, Berkow LC, Kudenchuk PJ, et al. European Resuscitation Council guidelines for resuscitation 2015: Section 3. [Medline]. --> no 3.) 2014. Pulseless electrical activity (PEA) and asystole are related cardiac rhythms in that they are both life-threatening and unshockable cardiac rhythms. ECG changes on continuous telemetry preceding in-hospital cardiac arrests. Heart Rhythm. Nichols R, Zawada E. A case study in therapeutic hypothermia treatment post-cardiac arrest in a 56-year-old male. During CPR, a rhythm check should be done every 2 minutes (5 cycles). A lack of circulating body fluids, principally blood volume. Adult advanced life support. Which of the following is possible reversible causes of a pea rhythm? 23(1):1-6. Littmann L, Bustin DJ, Haley MW. PR interval is unable to be measured due to no P waves being present. PEA caused by HYPERkalemia may present with which of the following rhythm changes? Once reversible causes of pulseless electrical activity (PEA) are identified, they should be corrected immediately. Jordan MR, Morrisonponce D. Asystole. Sandy N Shah, DO, MBA, FACC, FACP, FACOI is a member of the following medical societies: American College of Cardiology, American College of Osteopathic Internists, American College of Physicians, American Medical Association, American Osteopathic Association, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and InterventionsDisclosure: Nothing to disclose. PEA along with asystole make up half of the Cardiac Arrest Algorithm with VF and VT consisting of the other half. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Setala P, Hoppu S, Virkkunen I, Yli-Hankala A, Kamarainen A. [Full Text]. StatPearls. PROGNOSIS OF PEA. PEA may be caused by many conditions, but its most frequent causes are hypovolemia and hypoxemia. By definition, patients with electromechanical dissociation (pulseless electrical activity) have relatively normal cardiac impulse formation and conduction. Thompson LE, Chan PS, Tang F, et al, for the American Heart Association’s Get With the Guidelines-Resuscitation Investigators. Next question. [Medline]. Shockable rhythm? [Medline]. IEEE Trans Biomed Eng. This is usually (though not exclusively) caused by some form of bleeding, anaphylaxis, or pregnancy with gravid uterus. Part 7: Adult advanced cardiovascular life support: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. list of "probable" or "reversible" causes, but does not give you a good way of either narrowing that list down or an order to rule things out • If the PEA is a narrow complex, look for obstructive causes first • If the PEA is a wide complex, look for metabolic causes first [Full Text]. Resuscitation. Sandy N Shah, DO, MBA, FACC, FACP, FACOI Cardiologist Pabst D, Brehm CE. While treating asystole, epinephrine should be administered as soon as possible without delaying the start or continuation of CPR. When all emergency treatments are unsuccessful, death is confirmed. Overall, OOHCA patients with PEA have poor outcomes (Andrew et al, 2014) survival to hospital discharge was 5.9% for PEA (compared with 1.1% for asystole) in survivors with 12-month follow-up data, the combined rate of death, vegetative state or lower severe disability was … 1977 Jan. 39(1):1-6. American College of Osteopathic Internists, Society for Cardiovascular Angiography and Interventions. [Medline]. It is identified by the presence of cardiac electrical activity with no corresponding mechanical pulse or signs of perfusion. 122(21):2116-22. Once these basic measures are in place, reversible causes should be sought and corrected. VT, and SVT). 121:1-8. Asystole is the “flatline” on the ECG monitor. [Medline]. 2008 Feb. 76(2):198-206. ACLS Cardiac Arrest PEA and Asystole Algorithm Perform the initial assessment Perform high-quality CPR Establish an airway and provide oxygen to keep oxygen saturation > 94% Monitor the victim’s heart rhythm and blood pressure If the patient is in asystole or PEA, this is NOT a shockable rhythm Continue high … 16(2):103-5. [Medline]. 2015 Nov 3. Healthcare providers should attempt to identify and correct an underlying cause if present. [Medline]. 33(7):891-4. AHA Advanced Cardiovascular Life Support Provider … Emerg Med J. Rules for Asystole and PEA Patients with PEA usually have poor outcomes. Hypovolemia and hypoxia are easily reversed and are the two most common causes of PEA. [Medline]. [Medline]. [Full Text]. Following the initial dose, epinephrine is given every 3-5 minutes as needed. Please confirm that you would like to log out of Medscape. Is pulseless electrical activity a reason to refuse cardiopulmonary resuscitation with ECMO support?. Resuscitation. Plast Surg Nurs. Peri-arrest treatment includes giving IV fluids and blood transfusions, and controlling the source of any bleeding - by direct … Ho ML, Gatien M, Vaillancourt C, Whitham V, Stiell IG. Resuscitation. [Medline]. Even in the rare case that a rhythm reappears, after 10-15 minutes or more the brain will have been deprived of oxygen long enough to cause brain … [Medline]. 2015 Jul. Shockable rhythm? Crit Care Med. [Medline]. Considering these causes, especially in light of the patient’s history, may help you to hone in on the underlying cause of the arrest and reverse it if possible. 2018 Feb. 35(2):89-95. Hypovolemia and hypoxia are the 2 most common underlying and potentially reversible causes of PEA. Eur Rev Med Pharmacol Sci. Circulation. [Medline]. An automatic system for the comprehensive retrospective analysis of cardiac rhythms in resuscitation episodes. Utility of prehospital electrocardiogram characteristics as prognostic markers in out-of-hospital pulseless electrical activity arrests. Rhythms and outcomes of adult in-hospital cardiac arrest. 2008 Mar. Resuscitation. Nadkarni VM, Larkin GL, Peberdy M, et al, for the National Registry of Cardiopulmonary Resuscitation Investigators. It is identified by the presence of cardiac electrical activity with no corresponding mechanical pulse or signs of perfusion. [Medline]. Due to this irresponsiveness, cardiac arrest may occur. [Medline]. Teodorescu C, Reinier K, Uy-Evanado A, et al. Hauck M, Studnek J, Heffner AC, Pearson DA. You should also be on the lookout for fluid shifts that may deprive the vasculature of blood volume; for instance, shifts caused by electrolyte imbalances can cause the overall fluid avail… Am J Emerg Med. No. A “flat line” is reserved for Asystole definition but PEA Med Princ Pract. Survival following cardiac arrest with asystole or PEA is unlikely unless a reversible cause can be found and treated effectively. 17(2):183-93. Hypovolemia and hypoxia are the two most common causes of PEA. Irrespective of the cause of cardiac arrest, early recognition and calling for help, including appropriate management of the deteriorating patient, early defibrillation, high-quality cardiopul… [Medline]. The immediate life-threatening problem is that this electrical activity is not associated with adequate mechanical (pumping) action, due for example to diffuse myocardial injury, pericardial tamponade, or severe loss of intravascular volume. torsade de pointes) or pulseless ventricular tachycardia. 295(1):50-7. Assess for ROSC and respond appropriately *If rhythm is shockable, … --> no 7.) Meaney PA, Nadkarni VM, Kern KB, Indik JH, Halperin HR, Berg RA. Do not attempt defibrillation if there is doubt about whether the rhythm is asystole or fine VF. These include the following: Jordan MR, Morrisonponce D. Asystole. 2015 Nov-Dec. 48(6):1062-8. Do DH, Hayase J, Tiecher RD, Bai Y, Hu X, Boyle NG. A. Always ensure that a reading of asystole is not a user or technical error. The two most common and easily reversible causes of PEA are: 1. trauma and hydrogen ion (acidosis) 2. trauma and hypoxia ... 3. search for possible causes … Electrocardiographic characteristics in EMD. JAMA. CPR for 2 mins, establish IV or IO access, 1 mg EPI every 3-5 mins, and consider advanced airway/capnography 4.) It is essential to search for and treat reversible causes for resuscitative efforts to be successful. Beta-blocker use and the changing epidemiology of out-of-hospital cardiac arrest rhythms. [Full Text]. What is the correct dosing regimen of epinephrine to treat PEA or Asystole? The proposal of an integrated ultrasonographic approach into the ALS algorithm for cardiac arrest: the PEA protocol. 2010 Nov 23. includes flat line as well as any other wave (except VF, A pacemak… Fuzaylov G, Woods B, Driscoll W. Documentation of resuscitation of an infant with pulseless electrical activity because of venous air embolism. [Guideline] Callaway CW, Soar J, Aibiki M, et al, for the Advanced Life Support Chapter Collaborators. [Full Text]. Teodorescu C, Reinier K, Dervan C, et al. Wagner BJ, Yunker NS. 2017 Sep 22. Consider all possible reversible causes for PEA utilizing a national recommended mnemonic of “H’s and T’s”: Asystole may be preceded by an agonal rhythm. Antipsychotic drugs are associated with pulseless electrical activity: the Oregon Sudden Unexpected Death Study. 2010 Nov 2. Acta Anaesthesiol Scand. With both asystole and PEA there is no blood flow to the brain unless immediate CPR is performed. Desbiens NA. [Guideline] Soar J, Nolan JP, Bottiger BW, et al, for the Adult advanced life support section Collaborators. [Medline]. The H's and T's that are possible causes of PEA include all the following except: 1. hypovolemia, toxins, thrombosis 2. hypoxia, thrombocytopenia, hypoglycemia 3. hydrogen ion, hypokalemia, tamponade 4. hypothermia, tension pneumothorax, hydrogen ion (acidosis) Sudden cardiac arrest is a major health care problem in the United States that accounts for up to 350,000 deaths per year27. [Medline]. PEA is a medical condition that is characterized by irresponsive mechanical pumping activity of heart, while rhythm or electrical activity of the heart remains normal. [Medline]. 2008 Feb. 36(2):391-6. [Medline]. Circulation. Long-term survival trends of Medicare patients after in-hospital cardiac arrest: insights from Get With The Guidelines-Resuscitation. Consider all possible reversible causes for PEA utilizing a national recommended mnemonic of “H’s and T’s”: 132 (16 suppl 1):S84-145. : Cardiac arrest ultra-sound exam--a better approach to managing patients in primary non-arrhythmogenic cardiac arrest. A pharmacologic review of cardiac arrest. 2017 Oct. 64(10):2411-8. 2018 Jan. 122:6-12. Hutchings AC, Darcy KJ, Cumberbatch GL. https://profreg.medscape.com/px/getpracticeprofile.do?method=getProfessionalProfile&urlCache=aHR0cHM6Ly93d3cubWVkc2NhcGUuY29tL2Fuc3dlcnMvMTYxMDgwLTEyMTM0Ni93aGF0LWFyZS10aGUtcmV2ZXJzaWJsZS1jYXVzZXMtb2YtcHVsc2VsZXNzLWVsZWN0cmljYWwtYWN0aXZpdHktcGVh, Toxins (eg, tricyclic antidepressants, digoxin, calcium channel blocker, beta-blockers). Paediatr Anaesth. Part 4: Advanced life support: 2015 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. 2015 Oct 20. However all patients with PEA will have no detectable cardiac output. A REASON Study. A retrospective study of pulseless electrical activity, bedside ultrasound identifies interventions during resuscitation associated with improved survival to hospital admission. AHA Advanced Cardiovascular Life Support Provider … [Medline]. All material on this website is protected by copyright, Copyright © 1994-2021 by WebMD LLC. Hernandez C, Shuler K, Hannan H, Sonyika C, Likourezos A, Marshall J. Teodorescu C, Reinier K, Uy-Evanado A, et al. Youngquist ST, Kaji AH, Niemann JT. Testa A, Cibinel GA, Portale G, et al. The ALS Algorithm Non-shockable Rhythm Arm of The ALS Algorithm – Reversible Causes of PEA The reversible causes of PEA will now be discussed in detail: Hypoxia Each patient’s inspired oxygen should be as close to 100% as possible. If the rhythm is a shockable rhythm, the algorithm advises the … Raizes G, Wagner GS, Hackel DB. CPR for 2 mins/treat reversible causes 6.) Arti N Shah, MD, MS, FACC, FACP, CEPS-AC, CEDS is a member of the following medical societies: American Association of Cardiologists of Indian Origin, American College of Cardiology, American College of Physicians, American Heart Association, Cardiac Electrophysiology Society, European Heart Rhythm Society, European Society of Cardiology, Heart Rhythm Society, New York Academy of MedicineDisclosure: Nothing to disclose. The full list of potential causes of PEA include all reversible causes of arrest, the H’s and T’s, which include and are listed online here: Hypoxia, which occurs following suffocation or failure of the lungs to … Luo S, Zhang Y, Zhang W, Zheng R, Tao J, Xiong Y. Prognostic significance of spontaneous shockable rhythm conversion in adult out-of-hospital cardiac arrest patients with initial non-shockable heart rhythms: A systematic review and meta-analysis. S D Med. 1989 Apr. Hypovolemia and hypoxia are the two most common causes of PEA. It is important to CONFIRM true PEA early in the management of the case. 2010 Feb. 14(2):77-88. Treatment of PEA is not limited to the interventions outlined in the algorithm. This process may involve needle decompression of pneumothorax, pericardiocentesis for tamponade, volume infusion, correction of body temperature, administration of thrombolytics, or … Am J Emerg Med. Crit Care Med. Factors associated with pulseless electric activity versus ventricular fibrillation: the Oregon sudden unexpected death study. Assessment of futility in out-of-hospital cardiac arrest. The reversible causes of PEA can be remembered with a mnemonic of sorts, the H’s and T’s. Aufderheide TP, Thakur RK, Stueven HA, et al. PEA may include any pulseless waveform except VF, VT, or asystole. If the individual has a return of spontaneous circulation (ROSC), proceed to post-cardiac arrest care. [Medline]. The possible mechanisms by which the above conditions can cause pulseless in PEA are the same as those recognized as producing circulatory shock states. If your patient has lost a great deal of blood, hypovolemia should be considered as a cause of PEA. 2009 Apr. The ACLS algorithm advises the treatment of reversible causes of arrest following the initial, two-minute cycle of chest compressions and a dosage of epinephrine, following an EKG reading of asystole or pulseless electrical activity (PEA). What are the reversible causes of cardiac arrest? [Medline]. Make sure pads have good contact with the individual, leads are connected, the gain is set appropriately, and the power is on. 2.) 2010 Jan. 38(1):101-8. 2017 Sep 29. Cardiac arrest with initial arrest rhythm of pulseless electrical activity: do rhythm characteristics correlate with outcome?. PEA, pulseless electrical activity is defined as any organized rhythm without a palpable pulse and is the most common rhythm present after defibrillation. C.A.U.S.E. Resuscitation. Make sure pads make good contact with the individual, all cables are connected, the gain is set appropriately, and the power is on. StatPearls. 2006 Jan 4. Rad AB, Eftestol T, Engan K, et al. Simplifying the diagnosis and management of pulseless electrical activity in adults: a qualitative review. The reversible causes of cardiac arrest can be … [Medline]. Sudden cardiac arrest and sudden cardiac death can happen in every health care setting. There may be a subtle movement away from baseline (drifting flat-line), but there is no perceptible cardiac electrical activity. [Medline]. Gaspari R, Weekes A, Adhikari S, et al. Circulation. These are (1) impairment of cardiac filling, (2) impaired pumping effectiveness of the heart, (3) circulatory obstruction and (4) pathological vasodilation causing loss of … Tension pneumothorax secondary to automatic mechanical compression decompression device. An agonal rhythm is a waveform that is roughly similar to a normal waveform but occurs intermittently, … Rad AB, Eftestol T, Irusta U, et al. Always verify that a reading of asystole is not an equipment failure. 2017 Nov. 61(10):1334-44. 2013 Apr. They are also the most easily reversible and should be … Shockable rhythm --> no 5.) A PEA rhythm can be almost any rhythm except ventricular fibrillation (incl. Treat a reversible cause can be almost any rhythm including a flat line ( asystole ) Algorithm VF... Impulse formation and conduction that accounts for up to 350,000 deaths per year27 reason to refuse cardiopulmonary resuscitation and cardiovascular. 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Not limited to the interventions outlined in the Algorithm cardiac output hauck M Studnek... Uy-Evanado a, Kamarainen a exam -- a better approach to managing patients in primary non-arrhythmogenic cardiac among. 7: Adult advanced Life support: 2010 American Heart Association guidelines update cardiopulmonary... Care setting exam -- a better approach to managing patients in primary non-arrhythmogenic cardiac rhythms... A palpable pulse and is the correct dosing regimen of epinephrine to treat PEA or asystole easily reversed and the. This maximises the chances of the cardiac arrest with initial arrest rhythm of pulseless activity... X, Boyle NG rhythm is asystole or PEA is not an equipment failure up to 350,000 deaths per.! ( incl use and the changing epidemiology of out-of-hospital cardiac arrest: insights from Get with the Guidelines-Resuscitation is major! Stueven HA, et al frequent causes are hypovolemia and hypoxia are the two most common of... Due to no P waves being present which of the following is possible reversible causes of a pea rhythm gravid uterus … a PEA rhythm be...

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