AudienceThis simulation-based scenario is appropriate for senior level emergency medicine residents.IntroductionPulseless electrical activity (PEA) accounts for up to 25% of sudden cardiac arrest;1therefore the ability to recognize and care for this condition is an essential skill of emergency medicine physicians. Management of PEA arrest in the emergency department centers on Advanced Cardiac Life Support (ACLS) algorithms and the identification and treatment of potentially reversible causes. Massive pulmonary embolism (PE) is one of several causes of PEA cardiac arrest.2However, diagnosis by CT-angiographic or nuclear imaging may not be obtainable in the hemodynamically unstable patient, requiring physicians to have a high index of suspicion. Systemic thrombolytic therapy is indicated in cardiac arrest due to known or presumed massive pulmonary embolism.3,4,5Educational ObjectivesAfter competing this simulation-based session, the learner will be able to:Identify PEA arrestReview the ACLS commonly recognized PEA arrest etiologies via the H &T mnemonicReview and discuss the risks and benefits of tissue plasminogen activator (tPA) for massive PEEducational MethodsThis is a high-fidelity simulation that allows learners to evaluate and treat a PEA arrest secondary to massive PE in a safe environment. The learners will demonstrate their ability to recognize a PEA arrest, sort through possible etiologies, and demonstrate treatment of a massive PE with tPA. Debriefing will focus on diagnosis and management of the PEA arrest.Research MethodsThis case was piloted with 12 PGY-2 and PGY-3 residents. Group and individual debriefing occurred post-case.ResultsPost-simulation feedback from the faculty suggested two potential issues. First was fidelity, which we increased by using our ultrasound simulator. Second, the elevated presenting glucose with lactic acidosis could be a poor cue, leading some towards diabetic ketoacidosis (DKA).DiscussionLearners felt more confident about running a PEA arrest. The simulation improved resident awareness of the value of point of care ultrasound (POCUS) in cardiac arrest. It also clarified the dosing of tPA in massive PE. Faculty felt simulating the actual US without breaking simulation would be more challenging without our US simulator. Although there was concern about results pointing towards possible DKA, this did not occur in any of the pilot simulations. The presenting glucose was reduced to make this less likely in future simulations.TopicsPulseless electrical activity (PEA), syncope, cardiac arrest, Hs and Ts from ACLS PEA instruction, tPA for massive PE, critical care medicine, simulation.