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Now let’s talk about asystole, sometimes referred to as a “flatline” on the monitor. It represents the absence of both electrical and mechanical activity of the heart. Now if the patient doesn’t have a pulse and asystole is confirmed in one lead, we should check another lead and the monitor’s amplitude to make sure it is not fine V-fib. Like in PEA, it’s also important to determine the H’s and T’s to discover why the patient went into cardiac arrest and to treat any reversible causes of asystole. Remember asystole is not a shockable rhythm and treatment for asystole involves high quality CPR, airway management, IV or IO therapy, and medication therapy which is 1mg epinephrine 1:10,000 every 3-5 minutes rapid IV or IO push. It’s rare for asystole to be reversed especially after a long duration. Although it is a difficult choice to stop resuscitation efforts, if the patient does not respond to the BLS and ACLS treatments, the decision to terminate resuscitative efforts needs to be made. And if you have a high degree of certainty that the patient will not respond to further ACLS interventions, it would be appropriate to stop. The decision must be based on your specific protocols and the consideration of time from collapse to CPR, time from collapse to first defibrillation attempt, underlying causes, response to resuscitative measures, and especially the ETCO2 less than 10 after 20 minutes of CPR. All will contribute to your decision to stop resuscitative efforts in the asystole patient.
Asystole, sometimes referred to as a flat line on the monitor, represents an absence of both electrical and mechanical activity in the heart. In this lesson, we'll dig a little deeper into what it is and how it can be treated. And at the end of the lesson, you'll find a Word about the duration of resuscitative efforts.
Pro Tip #1: It's important to understand that if a patient has no pulse and this is confirmed in one lead, there are a few things you can double-check to confirm this, such as:
Like pulseless electrical activity (PEA), it's also important to determine what may have caused the patient's asystole, or in other words, examine the H's and T's. If you can figure out why the patient went into cardiac arrest, looking at the H's and T's will help you determine the possibility of treating any reversible causes of the asystole.
Those H's and T's are:
Pro Tip #2: Asystole is not a shockable rhythm. So, treatment will involve high-quality CPR, airway management, IV or IO therapy, and medication therapy – specifically 1mg of epinephrine 1:10,000 concentration every 3 to 5 minutes via rapid IV or IO push.
Having said that, it's rare for asystole to be reversed, especially if the patient has been in asystole for a long duration of time.
Stopping resuscitation efforts is never an easy choice to make, and this is a gross understatement. However, if the patient is not responding to all of your basic and advanced cardiac life support treatment attempts, the decision to terminate resuscitation will need to be made.
If you have a high degree of certainty that the patient will not respond to further ACLS interventions, then it would be appropriate to stop.
As stated above, this will never be an easy decision. And the decision to do so must be based on your specific protocols and consideration of the following criteria:
All of the above should be considered before deciding to terminate your resuscitation attempts in all patients in asystole.
While we already provided you with a list of criteria above that you can use to make this very difficult decision, let's dig a little deeper into the duration of resuscitative efforts.
Deciding to terminate resuscitative efforts can never be as simple as an isolated time interval. If the return of spontaneous circulation of any duration occurs, it may be appropriate to consider extending your resuscitative efforts.
Experts have developed clinical rules to assist in decisions to terminate resuscitative efforts for in-hospital and out-of-hospital arrests. However, you should also familiarize yourself with the established policy or protocols for your hospital or EMS system.
You should consider the continuation of out-of-hospital resuscitative efforts until one of the following occurs:
It might also be appropriate to consider other issues, such as drug overdose and severe prearrest hypothermia, due to submersion in icy water, for instance, when deciding whether to extend resuscitative efforts.
Special resuscitation interventions and prolonged resuscitative efforts might be indicated for patients with hypothermia, drug overdose, or other potentially reversible causes of the arrest.