--- title: 62-year-old woman presents after being treated at the scene for (PEA) description: It's PEA Quiz Time with Med-Challenger! image: https://challengercme.com/hubfs/Blog%20-%2062-year-old%20woman%20presents%20after%20being%20treated%20at%20the%20scene%20for%20(PEA).png --- [![Med-Challenger-green-logo-1024x244](https://challengercme.com/hubfs/Med-Challenger-green-logo-1024x244.webp) ](https://challengercme.com/) - [SHOP EXAM PREP & CME ](https://challengercme.com/blog/62-year-old-woman-presents-after-being-treated-at-the-scene-for-pea#) ### [EMERGENCY MEDICINE](https://challengercme.com/emergency-medicine-exam-review-cme-course) [ABEM exam prep](https://challengercme.com/emergency-medicine-exam-review-cme-course), [MyEMCert](https://challengercme.com/emergency-medicine-myemcert-exam-review-course), etc. ### [FAMILY MEDICINE](https://challengercme.com/family-medicine-exam-review-cme-course) [ABFM exam prep](https://challengercme.com/family-medicine-exam-review-cme-course), [ABFM KSA](https://challengercme.com/family-medicine-moc-ksa-course), etc. ### [INTERNAL MEDICINE ABIM exam prep, MOC points, etc.](https://challengercme.com/internal-medicine-exam-review-cme-course) ### [OBGYN ABOG exam prep, CREOG, etc.](https://challengercme.com/obgyn-exam-review-cme-course) ### [PEDIATRICS ABP exam prep, MOCA-PEDS, etc.](https://challengercme.com/pediatric-medicine-exam-review-cme-course) ### [PEDIATRIC EM](https://challengercme.com/pediatric-emergency-medicine-3rd-edition) [ABP/ABEM exam prep Ed.3](https://challengercme.com/pediatric-emergency-medicine-3rd-edition), [Ed.2](https://challengercme.com/pediatric-emergency-medicine-pack2), etc. ### [SPECIAL PURPOSE / SPEX FSMB exam prep, etc.](https://challengercme.com/special-purpose-exam-review-spex-exam-preparation-course) ### [PHYSICIAN ASSISTANT](https://challengercme.com/physician-assistant-exam-review-cme-course) [PANCE / PANRE](https://challengercme.com/physician-assistant-exam-review-cme-course), [CAQ-EM](https://challengercme.com/pa-caq-em-review-course), etc ### [NURSE PRACTITIONER](https://challengercme.com/family-nurse-practitioner-exam-review-cme-course) [FNP](https://challengercme.com/family-nurse-practitioner-exam-review-cme-course), [ENP](https://challengercme.com/emergency-nurse-practitioner-exam-review-cne-course), [AGNP](https://challengercme.com/adult-gerontology-nurse-practitioner-exam-review-cne-course), [PNCB/CPNP](https://challengercme.com/pediatric-nurse-practitioner-exam-review-cne-course), etc. ### [NURSING / NCLEX NCLEX, CNE, etc.](https://challengercme.com/nursing-certification-nclex-exam-review-cne-courses) ### [STATE-REQUIRED CME / CE State CME requirements, etc.](https://challengercme.com/state-required-cme) ### [JOINT COMMISSION CME](https://challengercme.com/stroke-center-ce-review-course) [Stroke](https://challengercme.com/stroke-center-ce-review-course), [Cardiac](https://challengercme.com/cardiac-center-ce-review-course), [Trauma](https://challengercme.com/trauma-center-ce-review-course), [ALS](https://challengercme.com/advanced-life-support-and-resuscitation-center-ce-review-course), etc. ### [PROFESSIONALISM CME Professionalism review with CME](https://challengercme.com/professionalism-review-course) ### [DERMATOLOGY CME Dermatology review with CME](https://challengercme.com/dermatology-review-course) ### [USMLE STEP 2CK / STEP 3 USMLE exam prep, etc.](https://challengercme.com/usmle-certification-exam-review-clerkship-exams-shelf-exam-review) - [INSTITUTIONS ](https://challengercme.com/atlas-pro-inst) - [BLOG ](https://challengercme.com/blog) - [SUPPORT ](https://support.challengercme.com/knowledge) [SIGN IN ](https://fuse.challengercme.com/sign-in?redirectURL=%2Fuserdash) emergency medicine # 62-year-old woman presents after being treated at the scene for (PEA) It's PEA Quiz Time with Med-Challenger! [ Med-Challenger ](https://challengercme.com/blog/author/med-challenger) Dec 5, 2024 [emergency medicine](https://challengercme.com/blog/tag/emergency-medicine) [Personal Education](https://challengercme.com/blog/tag/personal-education) [Question of the Week](https://challengercme.com/blog/tag/question-of-the-week) [quick quiz](https://challengercme.com/blog/tag/quick-quiz) ### < [All Posts](https://challengercme.com/blog) ABEM Exam Prep + CME Med-Challenger Emergency Medicine Pass-guaranteed ABEM exam review with CME built-in. Try it for free. On sale now. 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However, she remained apneic and was successfully intubated in the field. She now has a pulse between 60 and 65 beats/minute, her blood pressure is 80/20 mm Hg, and she has persistent apnea unless ventilated. The paramedics report that she did not require sedation either before or after intubation. Her pupils are miotic but symmetrical. Results on computed tomography (CT) of her head are normal, as are initial findings on a basic metabolic profile and bedside glucose determination. She was thought to be down about 3 minutes prior to the arrival of emergency medical services. Her blood pressure has changed only minimally after a trial of normal saline bolus 500 mL. The first treatment of choice for this patient is which of the following? - Naloxone - Dobutamine - Norepinephrine - Dopamine The correct answer is: Naloxone   **Educational Objective:** Appropriately implement the opioid algorithm used by the American Heart Association. **Key Point:** Between the years 2016 and 2017, opioid overdose cases have risen by 31% among those aged > 55 years (with the sharpest increase seen in the Midwest). **Explanation:** This patient should be treated with naloxone. This case represents a real patient who presented with an undisclosed heroin overdose. She did not have track marks on her arms, so the heroin overdose in this older patient initially went unrecognized. Rather, her miotic pupils led to an initial diagnosis of pontine stroke. However, results on CT were normal and her sodium levels were within normal limits. Hypoxic brain injury was also considered, but lack of response to the fluid bolus finally raised the concern for toxic overdose. Once that was considered, it became clear that the symptoms of bradycardia, relative hypotension, miotic pupils, and persistent apnea all pointed to that diagnosis. Thus, the patient was given naloxone and immediately awoke and then became combative. This scenario underscores an important point to remember: Although they are useful, Advanced Cardiac Life Support (ACLS) guidelines cannot cover every case. The health care professional must always consider pseudo-electromechanical dissociation when an organized rhythm is present in the absence of a pulse. Drug overdose is one of the well known but easily overlooked causes of PEA. Because opioid overdose is unresponsive to standard ACLS algorithms, the 2015 American Heart Association (AHA) guidelines added a new algorithm for opioid overdoses (see Figure). ![image (35)](https://challengercme.com/hs-fs/hubfs/image%20(35).png?width=875&height=1351&name=image%20(35).png) **References:** Centers for Disease Control and Prevention. Opioid overdoses treated in emergency departments. Published 2018. Accessed August 20, 2018. American Heart Association. [Web-based Integrated Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care](https://eccguidelines.heart.org/circulation/cpr-ecc-guidelines/part-10-special-circumstances-of-resuscitation/) (This site blends the 2019 Focused Updates with the 2015 AHA Guidelines for CPR and emergency cardiovascular care). Part 10: Special Circumstances. (accessed on April 16, 2020) Lavonas EJ, Drennan IR, Gabrielli A, et al. [Part 10: special circumstances of resuscitation: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care](https://www.ahajournals.org/doi/10.1161/CIR.0000000000000446). *Circulation*. 2015;132(suppl 2):S501-S518. Nikolaides JK, Thompson TM. Opioids (chapter 156). In: Wall R, et al. *Rosen’s Emergency Medicine: Concepts and Clinical Practice*. 9th ed., 2018:1943-1946. Szpilman D, Bierens J, Handley A, Orlowski J. Drowning*.* *N Engl J Med*. 2012;366(22):2102-2110. Vanden Hoek TL, Morrison LJ, Shuster M, et al. [Part 12: cardiac arrest in special situations: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care](https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.110.971069). *Circulation*. 2010;122(18 suppl 3):S829-S861.   This question appears in [Med-Challenger Emergency Medicine Review with CME](https://challengercme.com/emergency-medicine-exam-review-cme-course) [Try for free and save](https://fuse.challengercme.com/fulltrial/184). Ace your exams and meet your CME/MOC requirements for just $35 a month! 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All rights reserved [Privacy Policy](https://support.challengercme.com/knowledge/what-are-your-terms-of-service-privacy-policy-user-agreement) ```json { "@context" : "https://schema.org", "@id" : "https://challengercme.com/blog#webpage", "@type" : "WebPage", "description" : "The Challenger Medical Education Blog offers informative patient cases, medical certification exam preparation courses and board exam review tips.", "inLanguage" : "en", "isPartOf" : { "@type" : "WebSite", "name" : "Med-Challenger", "url" : "https://challengercme.com/" }, "mainEntityOfPage" : { "@id" : "https://challengercme.com/blog", "@type" : "WebPage" }, "name" : "Challenger Medical Education Blog", "primaryImageOfPage" : { "@type" : "ImageObject", "url" : "https://challengercme.com/hubfs/Webpage%20Featured%20Images/Medical%20Education%20Blog%20-%20Free%20CME%20resources%2c%20certification%20exam%20tips%2c%20clinical%20challenge%20questions%20and%20more.png" }, "publisher" : { "@type" : "Organization", "name" : "Challenger Corporation", "url" : "https://challengercme.com/" }, "url" : "https://challengercme.com/blog" } ``` ```json { "@context" : "https://schema.org", "@type" : "BlogPosting", "about" : [ "Pulseless electrical activity (PEA)", "Opioid overdose", "Naloxone", "Advanced Cardiac Life Support (ACLS)", "American Heart Association opioid algorithm", "Intubation and apnea management", "Bradycardia and hypotension", "Emergency medical services (EMS)", "Medical education and exam preparation" ], "articleSection" : "Emergency Medicine", "author" : { "@type" : "Organization", "name" : "Challenger Corporation" }, "dateModified" : "2024-12-05T18:56:10.054Z", "datePublished" : "2024-12-05T18:56:09.000Z", "description" : "It's PEA Quiz Time with Med-Challenger!", "headline" : "62-year-old woman presents after being treated at the scene for (PEA)", "image" : [ { "@type" : "ImageObject", "description" : "Med-Challenger Medical Education, a Division of Challenger Corporation", "url" : "https://challengercme.com/logo.png" } ], "inLanguage" : "en-US", "keywords" : [ "PEA", "pulseless electrical activity", "opioid overdose", "naloxone", "ACLS", "AHA opioid algorithm", "intubation", "emergency medicine", "exam prep", "CME" ], "mainEntityOfPage" : { "@id" : "https://challengercme.com/blog/62-year-old-woman-presents-after-being-treated-at-the-scene-for-pea", "@type" : "WebPage" }, "publisher" : { "@type" : "Organization", "logo" : { "@type" : "ImageObject", "url" : "https://challengercme.com/logo.png" }, "name" : "Challenger Corporation" } } ``` ```json { "@context" : "https://schema.org", "@type" : "QAPage", "mainEntity" : { "@type" : "Question", "acceptedAnswer" : { "@type" : "Answer", "text" : "Naloxone. The article describes this presentation as an opioid (heroin) overdose with bradycardia, relative hypotension, miotic pupils, and apnea unresponsive to fluids; naloxone administration immediately reversed the condition and the patient awoke. The piece emphasizes applying the American Heart Association opioid algorithm in such scenarios." }, "name" : "First treatment of choice for this patient?", "text" : "A 62-year-old woman treated at the scene for pulseless electrical activity (PEA) received epinephrine and was intubated. She now has a pulse 60–65 beats/min, blood pressure 80/20 mm Hg, is persistently apneic unless ventilated, and has miotic but symmetrical pupils. CT head and initial basic metabolic profile are normal, and she did not require sedation. A 500 mL normal saline bolus produced minimal change. What is the first treatment of choice? Options: Naloxone; Dobutamine; Norepinephrine; Dopamine." } } ``` ```json { "@context" : "https://schema.org", "@type" : "ItemList", "description" : "Exam-style review questions based on this article’s teaching points.", "itemListElement" : [ { "@type" : "ListItem", "item" : { "@type" : "Question", "acceptedAnswer" : { "@type" : "Answer", "text" : "Naloxone — in the described case, naloxone reversed apnea and altered mental status, illustrating opioid overdose as a cause of PEA and the relevance of the AHA opioid algorithm." }, "name" : "What is the first-line treatment for suspected opioid overdose presenting as PEA with miotic pupils?" }, "position" : 1 } ], "name" : "Practice Questions", "numberOfItems" : 1 } ```