Date Published

November 23, 2023

Updated For

ALS PCS Version 5.2


Direction for non-TOR Patients

Paramedics can take multiple factors into consideration and use their judgement to initiate transport before the 20-minute mark of resuscitation in patients who do not meet TOR criteria. This can include but is not limited to:

  • Younger age
  • Distance to hospital
  • Arrest witnessed by paramedics
  • Availability of ACP level of care for epinephrine administration
  • Ability to perform high quality chest compressions and resuscitative care during extrication and transport. This may include on scene and extrication/transport resources such as additional paramedic crews, firefighters, mechanical CPR devices etc.
  • Non-agonal PEAs (ex. heart rate greater than 60 and ETCO2 ≥ 30 in keeping with potential circulatory perfusion


Pulseless Electrical Activity

Pulseless electrical activity (PEA) occurs when a patient presents in cardiac arrest with organized or semi-organized electrical activity in the heart without a palpable pulse.

  • PEA is split into two sub-types that are distinguished based on visualized cardiac activity (may not be possible prehospital):
  • True PEA
  • Pseudo-PEA


True PEA vs. Pseudo-PEA\

True PEA: Presence of an organized electrical cardiac rhythm without cardiac muscle activity. (Cardiac Standstill)

Pseudo-PEA: Presence of organized electrical cardiac rhythm with cardiac muscle activity, pulse may not be palpated. (Profound Shock State)

Differentiating between the two types is typically preformed in hospital with bedside Ultrasound.

Prehospitally, an ETCO2 value of >30mmHG during resuscitation is suggestive of pseudo-PEA.

Management of PEA

  • ABCs
  • Continuous CPR 
  • Compressions 120/min, 10 breaths/min, 30:2 ratio if no SGA/ETT
  • Advanced Airway, Ventilation, ETCO2 monitoring, IV Access
  • 1mg Epinephrine (1:10000) IVP or IOP q 4mins (ACP)
  • Address H’s & T’s 
  • Consider early transport to hospital if PEA is determined non-agonal (PEA with HR >60BPM and ETCO2 >30mmHg in keeping with potential circulatory perfusion


Additional Resources:

Questions? Please contact our main # at (519)-667-6718 and ask to speak to a PHCS or email us @ [email protected] 

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