BACKGROUND Pulseless electrical activity (PEA) secondary to both blunt and penetrating trauma is associated with minimal survival. The pericardial view of the focused abdominal sonography for trauma (p-FAST) can differentiate between patients with and without organized cardiac activity and may assist in the decision to terminate ongoing resuscitation. METHODS A retrospective review was performed for all patients presenting to a level I trauma center from January 2006 through January/2009 who had PEA on arrival or developed PEA in the emergency department. Additional data abstracted included outcome, the p-FAST findings, and mechanism of injury. Recorded FAST examinations were reviewed by a blinded ultrasound trained physician. RESULTS During the study period 25 patients presented with PEA and three developed PEA during initial resuscitation. Contractile cardiac activity was present in nine patients with PEA on presentation and immediately after deterioration to PEA in the three patients developing PEA. Four patients had a penetrating mechanism and 24 were blunt. Two pericardial effusions were present on examination, both after blunt trauma. Three patients survived beyond the emergency department (89% early mortality). The survivors had presented in PEA with organized cardiac contractile activity on ultrasound and had tension pneumothorax, tension hemothorax, and hypovolemia treated. Two patients died in the operating room of uncontrolled hemorrhage and one patient died 6 days after admission because of closed head injury. CONCLUSIONS The presence of PEA at any time during initial resuscitation is a grave prognostic indicator. p-FAST is a useful test to identify contractile cardiac activity. p-FAST may identify those patients with potential for survival.