1-1 Asystole (1)

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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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