PEA: Without a Pulse

What PEA Means

PEA means pulseless electrical activity. The monitor shows organized, or partly organized, electrical activity, and the patient has no palpable central pulse. The heart may still be making electrical signals. It is not delivering blood to the brain.

This is a condition, not one special strip. Sinus bradycardia, an idioventricular rhythm, a junctional rhythm, or another organized shape can all be PEA. The shared feature is organized activity and no pulse.

Keep the arrest states straight. VF and pVT are shockable ventricular rhythms without a pulse. VF means ventricular fibrillation. pVT means pulseless ventricular tachycardia. Asystole is a flat line after you verify it. PEA is organized activity without a pulse, and it is not shockable. The wrong name leads to the wrong path. Do not shock PEA. Do not skip CPR.

Why this matters

A clean-looking complex does not mean the heart is moving blood. If you say only “sinus bradycardia at 40” and skip the pulse check, the team may treat bradycardia while the patient needs CPR.

The scene is noisy. You may have motion artifact, a weak femoral pulse, gloves, and cold limbs. Look at the patient, feel a central pulse on the brief check, then name the rhythm and the pulse. The sat waveform and the automatic cuff lie when perfusion is terrible. They do not replace a pulse check.

During CPR, keep pulse checks short and tie them to the rhythm check. Do not extend the pause to debate whether the complex looks good.

Clinical sequence

1. If you see organized complexes, feel a central pulse on the brief check. Use the carotid or femoral artery, as you were trained. No pulse means PEA. Do not call it sinus bradycardia with a pulse.
2. Say the shape first, then the pulse. For example: “Organized sinus bradycardia, no pulse. This is PEA. Continuing CPR, epinephrine on the protocol clock, looking for reversible causes.”
3. Keep high-quality CPR. Give epinephrine on the protocol clock. Look for reversible causes you can treat in the field: hypoxia, low volume, tension pneumothorax, high potassium, or a toxin.
4. Do not shock PEA. Do not chase a cuff blood pressure. If a pulse returns, switch to the ROSC package. ROSC means pulses are back.

Key points

• PEA is not a special waveform. Do not wait for a special look on the screen.
• Do not call PEA if there is a pulse. That is a living patient with a rhythm problem, such as symptomatic bradycardia. A weak pulse is still a pulse. Use the bradycardia or shock pathway, not the PEA plan.
• Watch for ROSC. A sudden rise in EtCO2, spontaneous movement, or an organized rhythm with a pulse means reassess. EtCO2 means end-tidal carbon dioxide. Do not keep doing CPR on a patient who has output.

Reversible Causes — Field Clues (Hs and Ts)

The list helps only if you tie it to the history, the exam, and the scene. Use it while CPR continues. Do not stop compressions for a long discussion.

• Hypoxia. Think airway obstruction, aspiration, drowning, opioid overdose, or failed oxygenation. Fix ventilation and oxygen delivery now.
• Low volume or bleeding. Think trauma, GI bleeding, an abdominal aortic aneurysm picture, pregnancy-related bleeding, or dehydration after missed dialysis. Control external bleeding. Give fluid or blood products only per protocol.
• Acidosis. Think a long downtime, diabetic ketoacidosis, or a toxic alcohol. Usually you treat it by ventilating and fixing the cause. Do not give bicarbonate by default.
• Low or high potassium. Think end-stage kidney disease, missed dialysis, crush injury, or certain poisonings. A wide complex or a sine-wave strip plus the history is the clue. Follow the high-potassium and arrest protocols when you are authorized.
• Hypothermia. Think outdoor exposure or cold water. Change your expectations and handle the patient gently, per protocol. Do not declare death in severe hypothermia without the local rule.
• Tension pneumothorax. Think trauma, high bagging pressure, one-sided findings, or obstructive shock. Decompress with a needle only if you are trained and protocol says to.
• Tamponade. Penetrating chest trauma is the classic story. Breath sounds may be equal, and the picture is obstructive shock. Move fast. Field options are limited.
• Toxins. Look for empty bottles, a bystander history, track marks, or an industrial exposure. Give an antidote only per protocol. For an opioid, naloxone fits when it will not stop CPR, or when there is a pulse and you are bagging.
• Clot in the heart or lung. Think an ACS history, or sudden collapse with risk factors for PE. ACS means a heart-attack workup. PE means pulmonary embolism. The hospital and reperfusion matter once you have ROSC.
• Glucose is not on the classic H list, but check it in undifferentiated arrest or PEA when it will not delay CPR. Low glucose is a reversible cause.

Common errors

• A pulse check that is too short, only on a wrist, or done during CPR so you feel a pulse that is not real.
• Mixing up PEA with asystole or fine VF. Those are different paths: shock versus no shock.
• Focusing on a pressor, the airway, or a long list of causes while CPR quality and short pauses fall apart.
• Calling PEA when there is still a pulse, only because the BP is low or the skin is mottled.
• Assuming a normal-looking QRS means the heart is pumping. Electrical activity is not mechanical output.

Practice

Related: Asystole vs Fine VF, Symptomatic Bradycardia.

Sources & Further Study

Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.

• NASEMSO National Model EMS Clinical Guidelines (2022) — U.S. EMS model language; protocol still wins
• AHA 2025 Part 9: Adult Advanced Life Support — PEA is a non-shockable arrest condition; hunt reversible causes during CPR
• The Hs and Ts are a teaching checklist to tie to the history and exam while CPR continues. They are not a reason to pause compressions.
• Your local cardiac arrest protocol, epinephrine timing, and medical direction.