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Continuing Education
Asystole
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Def inition: Asystole
Asystole is defined as the complete absence of electrical
activity in the myocardium (heart muscle).
Usually this represents extensive myocardial ischemia
(insufficient blood supply) or infarct (damaged tissue), with avery grim prognosis.
Most often, asystole represents a confirmation of death as
opposed to a dysrhythmia requiring treatment.
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Additional Inf ormation
Unless Appendix C (cessation of resuscitation) applies, the
team leader must consider the differential diagnosis while
beginning and maintaining CPR and interventions.
Asystole should not be defibrillated, as the increased vagaltone may prevent resuscitation. If able to do so, rescuers
should confirm asystole when faced with a flat line on the
monitor.
One should always consider these possible causes of asystole
and manage accordingly: drug overdose, hypokalemia,
hypoxemia, hypothermia, and pre-existing acidosis.
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Additional Inf ormation
Asystole can be primary or secondary.
Primary asystole occurs when the heart's electrical system
intrinsically fails to generate a ventricular depolarization.
This may result from ischemia or from degeneration (i.e.,sclerosis) of the sinoatrial (SA) node or atrioventricular (AV)
conducting system.
Primary asystole usually is preceded by a bradydysrhythmia
due to sinus node block-arrest, complete heart block, or both.
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Causes
Reflex bradyasystole/asystole can result from:
ocular surgery
retrobulbar block
eye trauma direct pressure on the globe,
maxillofacial surgery,
hypersensitive carotid sinus syndrome, or
glossopharyngeal neuralgia.
Episodes of asystole and bradycardia have been documentedas manifestations of left temporal lobe complex partialseizures.
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Causes
Secondary asystole occurs when factors outside of the heart's
electrical conduction system result in a failure to generate any
electrical depolarization.
In this case, the final common pathway is usually severe tissuehypoxia with metabolic acidosis.
Asystole or bradyasystole follows untreated VF and commonly
occurs after unsuccessful attempts at defibrillation.
This forebodes a dismal outcome.
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Morbidity and Mortality
Resuscitation is likely to be successful only if it is
secondary to an event that can be corrected
immediately, such as a cardiac arrest due to choking
on food (a cafe coronary), and only if an airway canbe established and the patient may be rapidly
reoxygenated.
Occasionally, primary asystole can be reversed if it is
due to pacemaker failure, which could be either
intrinsic or extrinsic, and this is corrected
immediately by external pacing.
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Assessment & Tr eatment Priorities
1. Ensure scene safety and maintain appropriate body substance
isolation precautions.
2. Determine unresponsiveness, absence of breathing and
pulselessness.3. Maintain an open airway with appropriate device(s), remove
secretions, vomitus, initiate CPR (push hard, push fast, limit
interruptions), and deliver supplemental oxygen, using
appropriate oxygen delivery device, as clinically indicated.
4. Continually assess level of consciousness, ABCs and Vital Signs.
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Assessment & Tr eatment Priorities
5. Obtain appropriate S-A-M-P-L-E history related to event,
including possible ingestion or overdose of medications,
specifically calcium channel blockers, beta-blockers and / or
digoxin preparations.
6. Every effort should be made to determine the possible causes
of asystole in the patient.
7. Initiate transport as soon as possible, with or without ALS.
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Tr eatment Procedur es
Basic Procedures ± NOTE: Inasmuch as EMT-Basics are unable to confirm the presence of Asystole,
check patient for pulselessness and manage according to the followingprotocol:
1. Early defibrillationa. Perform CPR until AED device is attached and operable.
b. Use AED according to the standards of the American HeartAssociation or as otherwise noted in these protocols and otheradvisories
c. Resume CPR when appropriate.
2. Activate ALS intercept, if available.
3. Initiate transport as soon as possible, with or without ALS.
4. Notify receiving hospital.
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ALS Interventions: What to
expect
CPR
± CPR is used to circulate blood to the brain and heart
Placing an Airway
± To ensure that CPR is delivering oxygen to the brain and
heart
Medications
± Used for various reasons
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ALS Medications Used in
Asystole
Atropine
Parasympatholytic agent
Used to eliminate vagal influence (decreased HR due to Vagus
Nerve stimulation) on SA and AV nodes. Not effective for infranodal third-degree heart block.
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ALS Medications Used in
Asystole
Epinephrine
± Considered the single most useful drug in cardiac arrest.
± Used to increase coronary and cerebral blood flow during
CPR. ± May enhance automaticity during asystole.
± Can be used for bradycardia in adult and pediatric patients.
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Prognosis
Prognosis depends on the etiology of the asystolic rhythm,timing of interventions, and success or failure of advancedcardiac life support.
Generally, the prognosis is dismal and postcountershock
asystole in particular has an even worse survival rate. When no shock is advised in patients with unwitnessed
cardiac arrest, there were no survivors in the Termination of Resuscitation study.
The most recent American Heart Association guidelines toimprove cardiocerebral resuscitation (CCR) have validatedstudies showing improved outcomes in all adults with out-of-hospital cardiac arrest in ventricular tachycardia andventricular fibrillation only.
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Massachusetts State Protocol
The Massachusetts State Protocol for Asystole is
Here:
± 1.1 Asystole (Cardiac Arrest)
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